How Diverse are State Medical Boards?

The Key Questions

While many of us have struggled personally with this question, we would propose that a clear and obvious opportunity exists for those of us working directly in, or with a close connection to, the world of medical regulation — specifically, the opportunity to examine the history of our institutions, whether they be public or private, governmental or academic. In scrutinizing our own institutions, we should pose key questions: What has been my institution’s experience and track record relative to justice, equity, diversity and inclusion (JEDI)? What efforts have been undertaken to promote JEDI? Are these efforts sufficient? One of the most powerful signals we can send is a willingness to look directly into our institution’s history, take stock of its failings (past or present), and document them publicly as a reference point for tracking the progress still needed toward social justice in this country.

To provide an example of the kind of inquiry being proposed, we present an informal review^* of the Federation of State Medical Boards’ (FSMB) governance. The question posed simply is this: “How well has FSMB achieved diversity in its elected board of directors?” We try to answer this question by looking over the FSMB Board of Directors’ composition over the past four decades, drawing on the authors’ individual and collective experience with the board and its leadership. However, we must preface our discussion by providing some background on the FSMB board.

The FSMB is a centenary organization established in 1912 as a membership association comprised of the individual state and territorial medical boards within the United States. The FSMB utilizes an elective process for selecting individuals to serve on its 15-member board of directors. Physician and non-physician members of state medical boards are eligible to serve.² Any current member of one of the FSMB member boards, as well as any former member no more than three years removed from service on their state medical board, is eligible to run for the board. All candidates for the board are reviewed by a nomination committee that puts forward a group of candidates to the FSMB House of Delegates for election. This House of Delegates is composed of a single representative from each medical board. Collectively this body elects both officers and members of the FSMB Board of Directors.³

We reviewed the composition of the FSMB board from 1980 to 2020. In selecting these dates, we made a conscious decision to go no earlier into the history of FSMB governance, as prior research revealed that no women or persons of color served on this governing board prior to the 1980s.⁴ Thus, analysis including the long period predating 1980 offers little additional insight into the organization’s governance and operations and would obscure trends evident and emerging from the past few decades.

Instead, we offer the photo on this page as indicative of the organization’s governance prior to the 1980s. This photo, from the year 1960, is like many that could have been shown for FSMB leadership. Whether plucked from 1930 or 1950 or 1980, the photo would have looked the same in one regard: leadership involved no one of color and no women. This photograph suffices as a succinct but accurate characterization of diversity prior to the 1980s. This would also likely reflect demographic trends in most medical leadership organizations at the time as well.

This photograph stands in marked contrast with the composition of the FSMB board in 2021. Women constitute 53% of current board membership (8:15); people of color (defined using U.S. Census Bureau categorization of anyone other than White, non-Hispanic) comprise 40% (6:15) of the FSMB board’s membership. This composition stands as the most diverse in the organization’s more than 100-year history.

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The FSMB Board of Directors Executive Committee in 1960.

A Demographic Portrait

During the period from 1980 to 2020, a total of 140 individuals served on the FSMB Board of Directors. Most of these board members were men (n=108) though nearly one-quarter were women (n=32). In terms of race/ethnicity, it appears that only 19 people of color served on the board over this period.

It is worth noting that this 40-year period witnessed significant demographic shifts in medicine and thus the pool of candidates who might serve on state medical boards shifted as well. For instance, in 2019, the Association of American Medical Colleges (AAMC) announced that for the first time over half of all matriculants to LCME-accredited programs issuing the M.D. degree were women.⁵ Similarly, AAMC data shows a continued, but slower, increase in non-white matriculants to medical schools.⁶

If one were so inclined, a comforting narrative could be presented using the information above and the long pre-1980 composition of the FSMB board. After all, when the starting point for diversity was its total absence, any change marks progress. Instead, we examined this 40-year period by breaking it into two shorter periods: 1980–1999 and 2000–2020.

Using the 1980–1999 time-period as a reference point for diversity in FSMB governance, it can reasonably be argued that the organization is trending particularly well in terms of the inclusion of women serving on governance. An appropriate comparative reference point for this is the 2018 FSMB Physician Census, which documents a male/female split of 64%-35% of all physicians with an active license.⁷ Measured against that metric, gender diversity on FSMB governance aligns well.

Progress appears more tempered in terms of racial/ethnic diversity. It seems that only five individuals that might not be classified as “White, non-Hispanic” served on governance from 1980–1999. The number rose to 17 for the most recent 20-year period, with the majority identified as Black or Asian (predominantly South Asian for the latter).

Contextualizing race/ethnicity information can be challenging. Complicating factors include individual self-identification (including reluctance in responding to such queries) and the absence of a single definitive resource for establishing this metric. An aggregated data set of active (2018) physicians from the AAMC offers perhaps the best accompanying metric. This listed 56% of U.S. physicians as White.⁸ However, this metric suggests FSMB governance still has significant room for diversity improvement in the area of race/ethnicity.

Structural Limitations

It is also important to view this information within structural and other constraints that impact diversity on a governing board. For example, in the case of the FSMB board, there are several distinctive features to the process by which individuals reach FSMB governance — features that directly impact the composition of this board.

First, the universe of potential candidates to run for the FSMB board is outside the control of either FSMB or its member boards. State medical board membership is generally appointive, with service resulting from gubernatorial appointment. It is unclear to what degree appointments to state medical boards routinely consider diversity.

The composition of the FSMB board is further dictated by the outcome of an election. Seats on this board’s governance are routinely contested with multiple candidates for an open position; seldom is there an uncontested opening. Thus, board diversity is a byproduct of the vagaries associated with any elective process.

Finally, a member appointed to a state medical board — whether physician or non-physician — may find considerable demands placed upon their time through this voluntary service. Thus, the universe of potential candidates is further constrained by each individual’s willingness and circumstantial ability to take on additional responsibilities with a national organization. These factors should be kept in mind in assessing the degree of diversity achieved on the FSMB board.

Whether one interprets the information we have shared here as a glass half full (evidence of significant progress) or a glass half empty (evidence of significant work still to be done) or both, data such as this provides an important point-in-time baseline. After all, it is difficult to know if our respective institutions are making progress toward diversity if we do not take the time to measure and document periodically.

Why is FSMB and State Medical Board Diversity Important?

Some may argue that all members of state medical boards and subsequent members of the FSMB governance are committed to their charge of protecting the public through the licensing of competent physicians and members of the medical workforce; and that diversity, while an important goal, should not be a factor or consideration outweighing this primary mission. Similarly, some would argue it is reasonable to presume that all board members, regardless of their background, will aspire to act impartially and represent the interest of all members of their jurisdiction.

The line of thinking outlined above is reasonable. However, on a deeper level, an explicitly stated commitment to diversity and inclusion in our state member boards enhances the perspectives and experiences of the board collectively — and in so doing, helps to ensure that groups that have been underrepresented historically on our boards see tangible evidence of progress toward justice, equity, diversity and inclusion. This explicit commitment can positively inform health policy decisions, affect complaint and/or case deliberations and ensure that the voices of more segments of the population are heard. How so? We would argue that by expanding the diversity of experience, perspective and culture of those in this critical role as decision-and policy-makers within medical regulation, we strengthen the depth of understanding and effectiveness for medical boards individually and collectively. As a regulatory community, we all stand to benefit from such combined efforts and their outcomes.

The Call to Action

To be clear, the information and data presented here do not represent sophisticated research or analyses. Indeed, the metrics applied are admittedly crude and the data set limited. We recognize this is a small first step. It does, however, serve as an illustrative example toward a larger purpose to which state medical boards can and should aspire. We offer it as a catalyst to a continued and necessary conversation and as a salutary challenge to the state medical board community. Accordingly, we offer the following two recommendations.

1. Members and staff of state medical boards committed to justice, equity, diversity and inclusion have a responsibility to undertake a similar look into their board’s composition and the mechanisms by which this is determined. Even if the review is done for no other purpose than to create a demographic/diversity baseline in 2022, this can have value going forward in seeking to identify trends or mark progress (or its absence) relative to the diversity of board membership.

2. The FSMB should consider undertaking a collaborative research effort with state medical boards to capture, document and publish a national portrait of state medical board membership — an analysis of the current aggregate composition of the approximately 800 individuals serving on state medical boards today. Such a project would provide an important benchmark to evaluate the diversity of state medical boards today in relationship to the U.S. physician workforce and the patient population that it serves.