The Missouri Medical Diploma Mill

 

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)

adcox 1

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.

st louis

 

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.

sutcliffe

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.

The Missouri Medical Diploma Mill

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.

Figure 2 St. Louis Star front page

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.

Figure 1 harry thompson

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 19th 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

 

The Medical Regulator’s Bookshelf

Every year roughly 10-15% of all the members serving on state medical boards across the country complete their term of volunteer service and rotate off their board. As this group exits, a new set of board members enter. This diverse group of new board members includes physicians, allied health professionals and members of the public drawn from all walks of life.

To get these new members up-to-speed, every state medical board conducts some type of orientation training for its new members. Invariably, this training focuses on practical matters specific to that state and its medical board, e.g., relevant state law, state ethics policy, board administrative operations, etc.

This training also represents an opportunity for broader, contextual education. It’s appropriate to learn the ins and outs behind state law and board operations but foundational knowledge is important too. It’s not enough to know how the current regulatory system runs; it important to know why the system operates in the shape it does today.

Indulge me as I play Professor Johnson and share my reading list for newbies enrolling in “Medical Regulation 101.”

Origins of Medical Licensure

Our course starts with James Mohr’s Licensed to Practice: The Supreme Court Defines the American Medical Profession. Mohr analyzed the backstory and implications of the US Supreme Court decision in Dent v. West Virginia (1889) that cemented state prerogative to regulate the practice of medicine. mohr book

Mohr does a marvelous job telling his story and teasing out the leap of faith that the justices made to rationalize the broad discretionary authority bestowed upon the profession and, by extension, medical regulators.   As Mohr pointed out, this was a leap of faith well beyond what was easily justifiable by the existing science of that day.  Looking back, the Court’s decision was less inevitable that we might imagine today.

 

An Overview of Medical Regulation

Okay, if I wanted to be humble, I would direct you to a pair of short works dating from the late 1960s by Robert Derbyshire and Richard Shryock…but dating (or in this case, “dated”) is the operative word. These texts were excellent but are now so old as to be of limited value for regulators today.j and h book

Instead, I’m going to assign David Johnson & Humayun Chaudhry, Medical Licensing and Discipline in America: A History of the Federation of State Medical Boards.    Yes, I’m recommending my own book and yes, the title suggests an organizational history; but hear me out. This organizational story is nested within a broader narrative tracing multiple main threads in the evolution of the current state-based system of medical regulation. And it addresses everything that followed Derbyshire and Shryock. Trust me, this is a better one-stop option for gaining a sense of the big picture. 

Board Dynamics

So what’s it like to serve on a medical board? How do boards—or more specifically, board members—approach their role, especially in disciplining physicians? Here’s one answer. ruth h book Take a professionally trained sociologist (Ruth Horowitz), place her as a public member on not one but two medical boards over the course of her career and you get this fantastic offering—In the Public Interest: Medical Licensing and the Disciplinary Process. This book should be shared with every new member to a state medical board—especially the public members. Her analysis is spot on and her recommendations apt.

 

 

Disciplinary Role of State Medical Boards

In terms of the disciplinary function of state medical boards, here’s your critical reading: State Medical Boards and the Politics of Public Protection by Carl Ameringer. This relatively slim volume explains the shift that occurred in medical boards’ philosophical approach to discipline beginning in the 1960s and gathering steam in the 1970s and 80s.

carl a bookI don’t want to oversell the shift tin discipline and mindset that occurred. Our system isn’t perfect (see Milwaukee Journal Sentinel). But we are headed the right direction compared to the veiled secrecy that  previously characterized medical boards’ operations in the area of discipline.

Another Ameringer work (The Health Care Revolution: From Medical Monopoly to Market Competition) presents a treat for board attorneys or public members with legal background as it traces the important case law impacting medical regulation.

 

Medical Licensing Examinations

Finally, there is an important 2009 essay by Donald E. Melnick. See “Licensing Examinations in North America: Is External Audit Valuable?” in the journal, Medical Teacher. One thing you’ll soon discover on your medical board is that the boards long ago left the business of writing their own exams and ceded responsibility for assessing prospective licensees to national entities such as the National Board of Medical Examiners, the Federation of State Medical Boards and the National Board of Osteopathic Medical Examiners. That doesn’t mean you have no responsibility or obligation in this area as a medical regulator. Statutes in every state require you to assess prospective candidates knowledge before issuing a license. Dr. Melnick’s short essay makes a persuasive case for the continued value of the assessment role played by state medical boards.

There are other important works I could advocate for but…I’ll stop here. After all this is our introductory course, right? So…you have your reading assignment. Class dismissed.

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

 

Some Origins of State-based Medical Regulation

In the years following the American Civil War (1861-65) multiple states and territories passed laws to regulate and limit the practice of medicine—specifically, requiring individuals to meet criteria set by the designated state entity (e.g., state board of medical examiners) and obtain a license before practicing medicine. Half a dozen states established medical licensing boards by the end of the 1870s, another dozen were established in the 1880s and most remaining jurisdictions did so in the 1890s.

For those with any familiarity on the subject, there is nothing new in what I just shared. The “when” in this evolving regulatory system can be presented in a straightforward chronology presenting the introduction of medical practice acts and the establishment of state medical boards.

However, the question of “why” is a different story. Specifically, why did state-based medical regulation emerge at that particular moment in America’s history? People had been practicing medicine long before any state laws regulating the practice—so why did the state legislatures suddenly feel it necessary to begin regulating medicine?

Here we enter speculative grounds but I would offer several reasons for the emergence of medical regulation in the post-Civil War era.

Push back against the “democratization” of medical care

In 1822, the New England folk healer Samuel Thomson published his “New Guide to Health; or Botanic Family Physician.” This modest beginning marked the start of Thomson’s widely successful efforts to re-establish the practice of medicine with its rightful practitioners and materia medica—specifically, family and friends drawing upon herbal or botanic-based remedies. Thomson’s success with direct to consumer guidebooks for medical practice and agents in the field selling his “system” of botanical remedies resonated deeply with Americans of that era increasingly adverse to privilege and hierarchy.

sam thomson

Thomson’s success irked physicians (no surprise!) who felt their knowledge and skill denigrated by home practitioners. When the home medicine-tide finally began to ebb in the post-Civil War era, physicians were already organized (i.e., AMA and state medical societies) and poised to push back. Physicians could point to major advances ongoing in medicine as a basis for establishing themselves as professionals with exclusive control over the practice of medicine. Staking out and securing their “turf” legislatively, including controlling entry into the profession, became a priority for physicians.

Explosive growth in the number of medical schools

At the opening of the 19th century, there were a handful of medical schools in America. By mid-century, there were  50 medical schools. By 1884, there were approximately 100 schools.

US map

Weak chartering laws and the didactic nature of US medical education meant that all that was required to establish a medical school was a building, a minimal amount of materials (books, lab supplies, access to cadavers) and a handful of physicians willing to collaborate as faculty. The result was a sharp increase in the number of individuals holding an actual medical degree and eager to seek a financial return on their modest investment through practicing medicine. Just as important, this era predates even de facto accreditation efforts. Consequently, wide variability in quality characterized US medical education.

From a demographic and educational perspective, this situation posed serious challenges for US physicians seeking to establish medicine as a legitimate profession. To use a metaphor, medical schools were like a faucet with a broken handle gushing forth newly-degreed physicians. It was impossible to cut off the flow; but if one attached new piping to the opening of the faucet, it would be possible to reduce the flow. The “new piping” was state legislation setting forth criteria for the legal practice of medicine and a designated authority (state medical board) empowered to evaluate individual qualifications and issue licenses. Statutory requirements could be set in such a way as to either restrict or encourage the flow of graduates from medical schools. Organized medicine worked doggedly toward restricting the flow.

Rise of the penny press newspaper

Medical societies and individual physicians had another stalking horse at their disposal in arguing for a medical practice act in their state –the quack[1] or the charlatan. Hawkers of medical cures and remedies can be traced into the Middle Ages where they often combined medical, theatrical and itinerant elements. With so many, at best, modestly educated practitioners pouring out of American medical schools—including those with degrees from schools little more than medical diploma mills—the medical establishment could point to outlier practitioners (conveniently labeled quacks or charlatans) as a tangible example of the need for medical legislation. snake oil

Their case was further bolstered by the ready availability of cheap print advertising in the daily penny press newspapers. Wild claims involving all manner of lotions, potions, pills, nostrums and elixirs filled newspapers, short-lived medical journals and circulars. Physicians could point to the over-the-top claims in these ads from outlier practitioners as proof of a danger to the public.

I would argue that all three forces were at work in the post-Civil War years; combining in a mutually reinforcing way that resulted in a steady push toward a state-based system of medical regulation.

The views expressed are those of the author and not the FSMB.

Resources:

William G. Rothstein, American Physicians in the Nineteenth Century: From Sects to Science (Baltimore: Johns Hopkins Univ. Press, 1985)

John S. Haller, Jr., The People’s Doctors: Samuel Thomson and the American Botanical Movement, 1790-1860 (Carbondale: Southern Illinois Univ. Press, 2000)

M. A. Katritzky, “Marketing Medicine: The early modern mountebank,” Renaissance Studies 15, no. 2 (2001).

 

[1]  Quack derives from the Dutch quacksalver meaning a hawker of salves.

Bias in Testing?

I spent time recently reviewing records from the North Carolina Medical Board spanning the late 19th and early 20th centuries. In doing so, I ran across a small parenthetical item that peaked my interest. Nestled discreetly next to the name of a physician who passed the board’s licensing examination in 1933 was this small notation — (c)

Further review of the board’s records for other years soon confirmed my suspicion as to the meaning of this notation. I found that in other years, the notation appeared as (Col) or (colored). As part of the segregated South, the North Carolina board’s records explicitly identified black physician candidates for medical licensure. (See image below)C designation

This finding did not surprise me considering the socio-politico and legal tenor of the times. But it did raise a question in my mind…or rather a series of questions. Why did the board’s secretary feel compelled to identify black physicians in their records? Was this a benign action merely consistent with routine administrative practices in most or all the state’s agencies? Or did this flagging of black physicians in the record point toward bias in the examining and licensing of these physicians? Ultimately, I found myself wondering, “Was the medical licensing examination in North Carolina conducted in a reasonably fair and unbiased manner for all candidates?”

This question seemed overly ambitious at first; but as I looked deeper into the board’s records, I realized that sufficient details had been captured that answering this question might just be possible. Specifically, the board’s records contained details on the administrative practices and scoring of their examination.

For example, the board’s examination was conducted as an essay exam spanning usually 3-4 days. The day prior to testing the candidates arrived and presented the board Secretary with their completed registration, credentials, references, etc.

A single member of the board was assigned to administer and then score specified content areas. (See the example from 1940 below).

test admin

To guard against potential bias in scoring, 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.

roster

Pseudonym shown at far left for examinees

This administrative protocol, if followed correctly, offered a reasonable mechanism to diminish the likelihood of bias.

The North Carolina board’s records also provided critical details related to scoring—specifically, the board routinely listed the actual scores (both passing and failing) for all candidates taking their examination. Similarly, these records capture the board’s composition for each administration of the exam, including identifying specific board members assigned to score papers for designated content areas.

These details make statistical analysis possible along several lines of inquiry. For example, pass percentages and mean and median performance by race and by medical school…and by cohorts reflecting changes in the North Carolina board’s composition.

I have not yet completed my analysis of this fascinating set of records spanning the period from 1886-1925. Stay tuned.

 

The  views expressed are those of the author and not the FSMB.

Con Man or White Collar Criminal?

I’ve spent a good deal of time writing and thinking about Dr. John Buchanan in recent years. His colorful career saw him play many roles including physician, author, educator, patent medicine entrepreneur and…criminal. His infamy, despite having been largely forgotten today, rests upon his latter role as the moving force behind America’s largest medical diploma mill in the 19th century. (See my forthcoming book Diploma Mill: The Rise and Fall of Dr. John Buchanan and the Eclectic Medical College of Pennsylvania from Kent State Univ. Press, August 2018.)

Johnson_Diploma Mill_amazon (002)

Over a career spanning roughly four decades, John Buchanan’s transgressive behaviors included the sale of medical degrees, conspiracy to defraud, bribery, apparent theft of corpses for anatomical instruction, allegations of criminal abortion and political chicanery designed to swing a state legislative election to one of his colleagues.

Buchanan’s career, while colorful, is not entirely unique. Scoundrels populate the history of medical regulation in America. The rogues’ gallery where Buchanan resides includes hucksters and charlatans like goat gland specialist John Brinkley, cancer-cure specialists like Norman Baker and Harry Hoxsey, snake-oil salesman Clark Stanley and countless locally infamous rascals that bedeviled state medical boards and the medical profession.[1]

 

(Left to right: John Buchanan, John R. Brinkley, Harry Hoxsey)

One of the questions I have found difficult to answer about Buchanan should be a simple one.  Why did he do it? Why did he risk—and ultimately throw away—a promising medical career at a legitimate educational institution?

Money—that’s the obvious answer, right? The diploma trade proved not only lucrative but relatively easy to conduct during the post-Civil War era despite the periodic outcry of critics.

But that doesn’t really answer the question. Think about it. There is nothing at this moment preventing you or I from engaging in an activity that could reap a financial windfall—drug dealing, income tax evasion, identity theft, various types of fraud, etc. And yet we don’t do these things from a mixture of motives, e.g., our sense of moral or ethical values, our fear of being caught and punished. Indeed, the vast majority of the human population rejects transgressive behavior on a daily basis in favor of our remaining in good standing in what is collectively hopefully a safer, stable, more just social order.

If greed doesn’t explain John Buchanan’s behavior, what does? Here I think it is helpful to see John Buchanan as a specific type of scoundrel in the medico-regulatory world. Not the confidence man of the sort represented by a Brinkley, Baker and their ilk but as a type we more often think of as a creature of the 20th century—the white collar criminal.

The federal prosecutors who charged Buchanan with mail fraud in 1880 attempted to portray him as a con man preying upon the public through his issuance of mail order diplomas that became the basis for some physicians to secure a medical license. While this was a rational argument to present in trying to secure a conviction on mail fraud charges, it represented an overreach. Why? Quite simply, no fraud entered into the transaction between Buchanan and the purchasers of the diplomas as both sides were aware of the true nature of the transaction. The judge agreed, acquitting Buchanan on this specific charge. (below left)

acquittal

No, unlike the con men fleecing naïve but ultimately trusting patients, John Buchanan acted in a manner more consistent with the white collar criminal. The term itself dates to the late 1930s and its introduction by the sociologist Edwin Sutherland. Generally defined as a non-violent offense involving financial motive, we generally think of white collar criminals as professional men who have exploited their position or authority for personal gain, e.g., Bernie Madoff, Jeffrey Skilling (Enron), etc.

Traditionally, scholars explained white collar criminal behavior in wholly rational terms—as individuals engaged in a conscious, almost deliberative mental process involving analysis of risk and reward related to a specific opportunity. More recent research,[2] including interviews with convicted white collar criminals, suggests a more nuanced explanation involving a triangulation of variables:

  • perceived pressure
  • perceived opportunity
  • individual integrity/rationalization

Here I believe we find the more compelling answer to why John Buchanan moved into diploma sales. Financial pressures on Buchanan and his school increased markedly in the early 1860s with the start of the Civil War and the disrupted flow of matriculating students. In his published confession from 1881, Buchanan also cited personal financial pressures.

As for opportunity, at the time Buchanan joined the school faculty in 1860, there were virtually no legal restrictions on the practice of medicine anywhere in the United States. As the professionalizing trend evolved in medicine, pressures mounted to increase standards for medical education, including the issuance of medical degrees. Legitimate degree issuance practices such as ad eundem and honorary degrees and the awarding of advance standing to experienced physicians were practices vulnerable to abuse for those willing to “rationalize” deviations from conventional or accepted standards.

In this regard, Dr. John Buchanan differed markedly from the contemporary charlatans knowingly peddling nostrums based upon hokum and pseudo-science to a gullible public. Buchanan’s downfall derived from the hubris of a criminal who convinced himself that his drift into questionable practices could be justified in the laissez-faire era of lax business practices and that his golden goose (the diploma trade) could lay eggs just a little longer despite the emerging regulatory landscape rapidly changing his world.

The opinions expressed reflect the views of the author and not those of the FSMB.

Sources:

David Alan Johnson. Diploma Mill: The Rise and Fall of Dr. John Buchanan and the Eclectic Medical College of Pennsylvania (Kent State Univ. Press, August 2018)

Bill Barrett. “Inside the Mind of the White Collar Criminal.” Accessed July 24, 2018 at https://www.accountingweb.com/technology/trends/inside-the-mind-of-the-white-collar-criminal

[1] See Pope Brock, Charlatan (New York: Three Rivers Press, 2008) and Eric S. Junhke, Quacks and Crusaders (Lawrence: Univ. of Kansas Press, 2002)

[2] Experts in the field have also identified psychopathic traits commonly seen among white collar criminals. See Isabella Merzagora, et. al., “Psychology and Psychopathology of White Collar Crime,” Organized Crime, Corruption and Crime Prevention October 2013.

The Nice Quiet 1950s, cont.

In my last blog entry, I shared the page (below right) from the 1953 FSMB annual meeting program. I did so in order to spotlight the fact that discipline was such a minor concern of state medical boards that as a topic it appeared only once (1953) on the formal program of the Federation’s  annual meeting during the decade of the Fifties.

FSMB 1953 program

I think any member of a state medical board or its staff looking at this today would find this remarkable. After all, they understand all too well the extent to which the disciplinary role is a time, labor and resource intensive element of medical boards’ functioning.

So what was going on during the 1950s? Certainly physicians in those days were not demi-gods immune to human flaws and failures. I think a couple factors were at work.

Medical boards of that era still thought largely in terms of the primary function envisioned for them at the time of their creation in the late 19th century—writing and developing an examination to assess physician knowledge prior to issuing a medical license.

Just how much priority and precedence did this aspect of medical boards’ activities take? It would be difficult to overstate the case.  Take this example. From 1906 to the mid-1960s, JAMA produced an annual issue featuring statistical data on the medical licensing examinations each year. (example below) Examinee counts, pass rates, licenses issued, statistical breakdowns by board, by medical school, etc. The list could go on for several paragraphs but my point is simple. Administering examinations and issuing licenses were the heart-n-soul of medical board activities in the 1950s. That is where they placed their greatest emphasis and focus.

JAMA stats

So what does this mean about discipline? Here I will offer the opinions of a few medical regulators of the day.   Asked about the disciplinary role of state medical boards in 1952, the FSMB’s own president said, “The influence of professional organizations coupled with the desire for the respect of fellow practitioners is usually sufficient.” One regulator, when asked about his board’s budget for disciplinary investigations, explained that “none is needed” because “discipline is…of secondary importance.”

Admittedly, the plural of anecdote is not evidence. Yet statements like these from medical regulators of that era seem telling.

This is not to say that state medical boards had abandoned their disciplinary role entirely. While no definitive national data exists for this period, my own count of disciplinary actions published through the Federation Bulletin found approximately 1,800 actions taken by boards between 1950 and 1959. To put that in at least some type of context, in 2015 medical boards in the U.S. took 7,000 actions that year alone.

Ultimately, the problem of discipline in that era was attitudinal. The regulators themselves did not see discipline as a priority; in part, because they presumed others were tending to this. Specifically, the literature of the day underscores a dominant theme: the assumption that the profession would address—and if necessary remove—its outlier actors. Along with this was a bristly reaction to anyone outside the profession asking questions about problem physicians or questioning the efficacy of professional self-regulation.

To many retrospective observers, the Fifties ended in 1961 when America’s then-oldest president (Eisenhower) gave way to our youngest elected president (JFK). The quiet so often ascribed to the Fifties in popular culture was really more a matter of willfully overlooking some of the disquieting and disturbing issues that some preferred not to think about. The same might be said for medical regulation in the 1950s as a blithe professional attitude toward discipline soon gave way in the 1960s to a siren call: the medical profession and regulators had to clean up their act and make discipline a priority…or else.

The views expressed are those of the author and not the FSMB.

Sources:

See Chapter 6 of Johnson, Chaudhry. Medical Licensing and Discipline in America: A History of the Federation of State Medical Boards (Lexington Books, 2012)

The Nice Quiet 1950s?

Popular culture seems to enjoy looking back at the 1950s and characterizing it as this quiet but fun era that preceded a raucous psychedelic Sixties. That decade is often remembered as a period of sock hops, big cars with large fins fueled by cheap gas, suburbia, a grandfatherly President (Ike), I Love Lucy and early rock-n-roll. This selective nostalgia seemed to peak in the 1970s with Happy Days and American Graffiti; then sporadically resurfaced in films like Back to the Future.

happy days

Of course, pop culture is not history. It doesn’t aspire to be history and should never be mistaken for it. Popular culture seems selective in forgetting all those elements of the 1950s that were neither quiet nor fun. This same period witnessed the Civil Rights movement and the often violent responses it drew in places like Selma, Birmingham and Greensboro. Baby boomers have vivid memories of duck-n-cover drills at school and fallout shelters amidst our Cold War with the Soviet Union.

I’m sure there’s an apt metaphor for this juxtaposition of perception and reality… …pressure building and then released. Maybe it’s a tea kettle or the smooth surface of a pond hiding a tree stump just below the water line. In some ways, medical regulation in the 1950s mirrored this juxtaposition.

A sense of this disquiet despite the relative calm in medical regulation can be seen in a retrospective look at two documents from this period.

Pictured below is a page from the program of the 1953 annual meeting of the Federation of State Medical Boards (FSMB).

FSMB 1953 program

At first glance, there is nothing particularly remarkable about the document. The program contains much that we might expect to see: remarks from the organization’s president; committee nominations; program sessions on medical board discipline; etc.

Every year since 1913, state medical boards in this country convened as part of the annual meeting of the Federation of State Medical Boards. These yearly gatherings allowed members and staff from medical boards to discuss issues great and small relative to medical regulation.

Yet there is something truly remarkable about this page of the 1953 FSMB annual meeting program that only becomes obvious in retrospect. That year’s program marked the only time during the entire decade of the 1950s that medical boards’ disciplinary role and function were featured topics on the agenda of the FSMB annual meeting.

Thing about this for a moment. The single biggest area of medical board activities today warranted virtually no time on the agenda in 1953. Over a ten year period and as the only forum for a national gathering of medical regulators, discipline appeared on the formal agenda only once!

How should we interpret this? What does this suggest about how medical boards once regarded their disciplinary role?  To be perfectly honest, the evidence suggests that…

  • Discipline represented a secondary function for medical regulators;
  • medical boards seemed not particularly interested in carrying out this role and function; and
  • medical boards once presumed that others (i.e., the profession through its local and state medical societies) were taking care of disciplinary matters.

How could this possibly be?

In my next blog post, I’ll share a second document from the 1950s that adds a little more context to our picture of medical regulation in the 1950s.

 

The views expressed are those of the author and not the FSMB.

The “lost” powers of state medical boards Part 2

Last time I explained the authority of state medical boards to identify “approved” and “unapproved” medical schools as one criteria in the decision to issue or deny a medical license—one of the “lost” powers of state medical boards. The information presented on the left side of the chart below reflects this information.[1] Now let’s explore the other side of the chart.

stats 1921

Co-existing with the statutory authority of state boards to issue a license for the practice of medicine is their primary historical function—developing and administering an exam to determine the knowledge of a prospective licensee.

As noted earlier, the quality of U.S. medical schools varied widely in the late 19th and early 20th centuries. Thus, the medical degree could not be accepted at face value as definitive evidence of preparedness to practice medicine. Accordingly, state medical boards were empowered to independently assess the knowledge of prospective licensees.

State medical boards—or the state board of medical examiners to use the more common title of that era—embraced this assessment role. Their exams typically were multi-day affairs relying upon open-ended questions, i.e., extended short answer or essay questions.

Look closely at the right side of this chart; one element jumps out immediately. The fail rate on these exams differed dramatically among the various states. At one end of the spectrum, sixteen states reported a fail rate of less than 1% on their licensing examination over the period from 1916-1920.

At first, I was suspicious whether this was accurate so I double checked the JAMA state board issues for this period. Sure enough, in places like Vermont and Idaho only 1-2 people failed during this entire period. Thus, a fail rate of less than 1% was accurate.

At the other end of this spectrum, five states reported fail rates of 22% or higher during this period. These weren’t all small states either. Heavily populated states like Massachusetts and Pennsylvania were in this cohort.

Furthermore, there didn’t seem to be a strong correlation between the number of schools not recognized by a state and the fail rate on its exam. Theoretically, we’d expect states like Delaware and Massachusetts to have lower fail rates because they already precluded so many graduates from substandard schools from sitting their exam. Yet, their fail rates were actually quite high—33% and 23% respectively.

Similarly, we might anticipate a higher fail rate in places like Utah and the District of Columbia since they precluded no one from sitting their exam. Yet, their fail rates were modest (5-7%) and well below the national average.

All of which leads to a suspicion that state medical board exams of this era were idiosyncratic tools that diverged markedly not only in their rigor (i.e., pass/fail standard) but probably to some extent in their content as well.

NBME logoIt is no wonder that the National Board of Medical Examiners developed and administered a certifying exam beginning in 1916 with eligibility criteria and professional standards designed to meet and exceed those of every state board exam…and no wonder that thirty-one states by 1925 accepted a pass on this exam as meeting their requirements for licensure.[2]

State medical boards remained in the business of creating licensing examinations until the late 1960s when the transition to nationally developed exams began. I’ll talk about that transition later.

Technically, state medical boards have not “lost” the power of assessment. What has happened is a shift in statutory language reflecting these boards’ responsibility to identify the examination(s) they will recognize and accept as evidence of medical knowledge: USMLE and COMLEX-USA.

USMLE logo

They have delegated (wisely) the daunting task of developing and administering their own medical licensing exam to professional entities with expertise in the science of assessment. In doing so, these boards retain their key role as an invaluable independent audit of medical education with their exam…but now they do so in concert with experts in assessment.

 

The opinions expressed are those of the author and not the FSMB.

[1] Federation Bulletin, June 1921, p.

[2] Johnson, Chaudhry. Medical Licensing and Discipline in America, 72.

The “lost” powers of state medical boards Part 1

State medical boards operate under-the-radar of most physicians and the public at large despite the fact they have been integral players in the U.S. medical regulatory system since their appearance in the last quarter of the nineteenth century.

By any objective measure, however, state medical boards exerted their greatest power and influence nearly a century ago.  I was reminded of this when I ran across this intriguing chart (below) from the June 1922 issue of the Federation Bulletin.

stats 1921

Take a closer look. The author of the article cobbled together statistics presented in JAMA’s annual report presenting statistics and information on the activities of state medical boards. The chart took a clever approach in consolidating two disparate pieces of information: state medical boards’ decisions to refuse licenses to graduates of certain schools and performance on their examination for medical licensure.

Let’s start on the left with state boards’ recognition of U.S. medical schools. With the exception of Massachusetts, Wyoming and the District of Columbia, every state board flagged a subset of schools that they refused to recognize for the purposes of licensing their graduates. Indeed, most of these boards identified 8-10 schools that they refused to recognize; nearly double that number in states like Pennsylvania and New Hampshire.

You’re probably wondering, “How was it possible someone could graduate from a US medical school and not be eligible for a license in most states?” To answer this question, we have to forget the medical education landscape as we know it in 2018.

We are so accustomed to the presence and function of trusted accrediting bodies for medical education (both undergraduate and graduate) that it’s easy to forget the realities of an earlier era.

In the first decades of the medical licensing (roughly the period from 1870 to 1910) there were no agencies or mechanisms providing assurance that anything substantive stood behind the issuance of a medical degree. At the time that state medical boards were established, they relied on generalized language (either in statute or developed by the board) that spoke in terms of licensing graduates of “reputable” or “legally chartered” schools.

Practical experience soon proved the uselessness of such language. A vague term like “reputable” offered little guidance and no measurable basis for distinguishing reputable from disreputable schools. Similarly, holding a legal charter was no guarantee. Even a medical diploma mill like the Eclectic Medical College of Pennsylvania held a valid, legal charter

Enter Dr. John Rauch and the Illinois Board of Health who quickly became the most influential players in the medical licensing community.

john h rauchRauch and his board colleagues embarked upon an ambitious information gathering effort that led to the first list of “approved” medical schools. A listing soon utilized by multiple states and claimed by several historians in recent years as being just as impactful as the later Flexner report.[1]

The American Medical Association (AMA) later took up the mantle of bolstering medical education standards with the creation of its Council on Medical Education. The Council undertook surveys and inspections in 1907-1908 that led to their own assessment of schools and a classification system. The Council classified medical schools into three groups. Schools of the highest quality were categorized as Class A; schools with deficiencies but still salvageable were categorized as Class B. The remainder (Class C) were deemed beyond the pale and believed to be unsalvageable.

By the time of the chart pictured here, medical boards were no longer as involved in investigating and monitoring the quality of medical schools. Instead, they drew upon the Council’s classification system to identify approved or recognized schools (Class A & B) and routinely deny licenses to graduates of Class C schools.

By the end of the 1920s, Class C schools had all but disappeared. Fast forward to 1942. This classification system evolved into the accrediting body that we know today for schools issuing the MD degree—the Liaison Committee for Medical Education (LCME).

Consequently, medical boards no longer have the need for formal lists of approved or recognized schools. The imprimatur of LCME accreditation assures medical boards of the meaningful education experience behind an MD degree.[2]

I would argue that this “lost” power of medical boards is a good thing…a positive reflection of just how far medical education and licensing have come over the past century.

Next time (in Part 2), we’ll look at the right side of this chart and the other “lost” power of state medical boards—state board examinations.

The opinions expressed are those of the author and not the FSMB.

[1]  See Lynn E. Miller, Richard M. Weiss, “Medical Education Reform Efforts and Failures of US Medical Schools, 1870-1930,” Journal of the History of Medicine and Allied Sciences (July 2008)

 

[2] The Commission for Osteopathic College Accreditation (COCA) accredits osteopathic medical education programs issuing the D.O. degree.