The History of the Federation of State Medical Boards: Part Two — Beginnings, Growth and Challenges, 1912–1929

Examinations for Medical Licensure

If today the American public generally associates the phrase “medical examiner” with forensics, no such connotation existed in the popular imagination a century ago. The ubiquitous presence of the term “examiner” in the name of most of the early 20th century state medical boards reflected their primary function in personally examining the fitness to practice of their licensure candidates. In this particular area, state boards experienced considerable success in their public protection role, even before the Federation's founding.

From the beginning of the second wave of medical licensing laws enacted across the United States starting in the 1870s, provision was made for an examination of physicians by a duly constituted examining board. Early on, the examination component was often one of several alternatives for being licensed. One review of state statutes for the period 1867 to 1895 concluded that 23 states either required an examination or offered one as a mechanism for obtaining a medical license. In most instances, the examinations were written, though an oral examination before the board seems also to have been likely since statutes often spoke in terms of the board's authority to “examine” a candidate without reference to the exam's format. The rigor behind these exams varied greatly between a pro forma exercise and an in-depth assessment lasting several days.5

Examination content varied markedly between states though some areas were commonly covered by most states, e.g., hygiene, anatomy, physiology, pathology, chemistry, surgery and obstetrics. Some boards were reluctant to assess therapeutics or materia medica as these areas led into philosophical differences among physicians concerning approaches to treating disease and illness. When board membership contained “regular,” homeopathic and eclectic physicians in proportional representation, they commonly allowed each the right to exam candidates in their respective area.6

Not all boards were reluctant to assess in contested areas. In states with separate homeopathic and eclectic boards, examinations could assess areas such as these without touching off contentious arguments. On occasion, even states with a single examining board, such as Missouri, addressed these areas directly though Missouri may have been atypical in this regard. The Texas approach — omitting contentious fields from the explicitly identified content of the exam — appears to have been more the norm in those states with a single board.7

As states expanded the breadth of coverage of their licensing exams, a simultaneous move to make them mandatory rather than an alternative to obtaining a license was also underway. In 1915, Federation Secretary-Treasurer Walter Bierring claimed that all states utilized some form of medical licensing exam. Progress in reaching this point had not come easily. It appears that by 1907 — and perhaps even earlier — all 46 states, the New Mexico and Arizona territories, and the District of Columbia were administering some form of written examination for licensure as evidenced by the annual state board issue of JAMA. What is less obvious are the requirements surrounding these examinations — specifically, whether they were mandated. Available evidence seems to indicate that by the time of Bierring's statement only New Mexico lacked a required exam as part of its licensure requirements.8

Another important question was how significant a challenge these exams represented for physicians. From a national perspective, the period witnessed a steady increase in the pass rate on these various exams. The pass rate for all states' exams reached 78–81 percent during the period 1904–1914, rising to 90–94 percent for the period 1925–1932. One explanation for this improvement stems from ongoing reforms in medical education. The decade prior to Abraham Flexner's 1910 report on U.S. medical education witnessed multiple new schools appearing and even more closing or consolidating. The latter trend accelerated after 1910 when the number of medical schools dropped from 133 to 65 “approved” medical schools in 1932. The rapid decline in proprietary schools meant fewer marginally or inadequately trained candidates sitting for medical licensing examinations. Meanwhile, graduates from approved medical schools accounted for an increasing percentage of all licensees — reaching nearly 94 percent in 1932.9

Another factor may have been the practice of crediting extra points, or an additional percentage, to the exam results of established practitioners previously licensed in another state. Texas, Illinois and Massachusetts utilized this practice. The lack of negative comments concerning this practice in the extant literature seems to indicate this was neither uncommon nor unexpected. It may have represented a political compromise designed to assuage the concerns of both “elderly” practitioners and state legislatures.10

A look at state-specific data reveals a wide variance in the pass/fail rates on these examinations. Between 1910 and 1913, the fail rates reported by each state on their medical licensing examination ranged from 0 percent to 45 percent. Thus, at the time of the Federation's founding, a significant variance existed in the standard that each state applied to its licensing examination. Twenty years later much of this wide variance in the range of pass rates disappeared. In 1929, 44 of 51 boards reported a failure rate of 12 percent or lower. Perhaps more significant was the preponderance of boards now reporting no failures at all on their state examinations. Whereas this was uncommon in 1910, by 1932 this was now the case for approximately half of all state boards.11 Such variability in the standard would continue to hinder efforts toward greater uniformity nationally.

The most important trend evidenced in medical licensing examinations during the first decades of the Federation involved the use of practical examinations. State boards had long suspected their written examinations were inadequate to “test the fitness” of prospective licensees as modern medicine seemed to demand “hands-on” clinical assessment. A 1917 survey revealed that 16 boards were already administering a practical examination in addition to their written exam, with many more strongly in favor of this approach.12

Hospitals and medical school facilities were utilized by most of the 16 boards, with the remainder conducting the assessment at board or state offices. This practical component varied considerably among boards to include laboratory work, use of medical instruments, and examinations using mannequins or even live human subjects. For example, Minnesota's candidates spent one day in written examinations followed by one half-day in laboratory work, with the remainder of that day spent performing a bedside examination. The written examination contained several major topics (medicine, surgery) and several minor topics (materia medica, therapeutics, medical jurisprudence, etc). Laboratory work included urinalysis and microscope analysis of specimens followed by physical diagnosis of a patient(s) at the nearby university hospital. The exam concluded with several state board examiners interviewing the candidate about the case(s).13

Perhaps the greatest impetus spurring state medical boards to think more seriously about the content and construct of their licensing examinations was the establishment of the National Board of Medical Examiners (NBME) in 1915. National Board founder William Rodman had long advocated for a voluntary national examining board to foster uniformity and physician mobility by authoring an examination representing a high standard that all state medical boards could accept for licensure qualification. The eligibility criteria for sitting the examination represented a standard equal to, or higher than, that mandated by any of the state boards. The examination lasted six days, covering not only cognitive knowledge but also practical aspects of medicine, including laboratory work and a bedside examination of patients. Results from the first administration in 1916 reflected the exam's rigor when only half of the 32 applicants were deemed to have met the educational prerequisites and only 5 of the 10 candidates who appeared for the examination passed.14

The Federation dedicated much of its 1916 annual meeting to the topic of the recently constituted National Board with tough questions and strong opinions coming from many attendees. Supportive state board members and Rodman addressed concerns and presented a persuasive case. Pennsylvania board president John Baldy spoke forcefully in addressing colleagues' concerns. While acknowledging that some state statutes might prohibit recognizing the National Board's proposed examination, he made clear that seeking statutory relief was nothing new to state boards seeking higher standards. He pointed to another voluntary national organization — the Association of American Medical Colleges — as evidence of the effectiveness of such bodies and their ability to gain support despite a lack of compulsory power. Ultimately, strong support from representatives of the Pennsylvania, Iowa, West Virginia, Kentucky, Ohio, Louisiana, Wisconsin and New Jersey boards carried the day, and the Federation endorsed the National Board.15

The National Board administered its first certifying exam in 1916, and within a year, 12 state medical boards had formally recognized this credential as meeting their medical licensing examination requirements. Steady progress continued, with 31 recognizing boards by 1925.16 Further evidence of Federation and state board support for the NBME was evidenced by the many members of the licensing community who subsequently served as members of the National Board.

License Reciprocity or Endorsement

At the time of the Federation's founding, reciprocal agreements between state medical boards seemed a viable solution to the problem of expeditiously licensing physicians relocating from one state to another. Such agreements had flourished in the early years of the 20th century. In 1912, they were still viewed favorably enough that the Federation's original bylaws incorporated the reciprocity standard. However, by the 1920s there were increasing reservations about use of such agreements.

The shift away from formal reciprocity agreements stemmed from several factors. Such agreements penalized the physician emigrating from a state that did not have a reciprocity agreement with the medical board in the new jurisdiction. Additionally, such agreements were deemed inadequate for dealing with applicants possessing questionable moral character. Some feared that state boards utilizing such agreements generally were not doing enough to investigate the physician's practice record and “standing in the community.” Even the language of the discussion had begun to shift. The term “reciprocity” fell into disfavor in the 1920s; instead, speakers began using the term ‘endorsement’ as one more reflective of a state board's decision to endorse the credentials of an applicant previously licensed elsewhere.17

A 1922 Federation survey of 18 southern states underscored the challenges inherent to administering an equitable process for reciprocity or endorsement. Sixteen of the 18 boards had some “fixed” process for reciprocal agreements but little consensus existed beyond the use of such agreements. Some boards adhered strictly to an examination requirement; others accepted candidates based upon a medical diploma and license from an originating state; others required both licensure examination and medical diploma. The details varied depending upon the specific agreement in place with a given state. The requirement for “practical experience” varied widely as well. Depending upon the state, upwards of five years of experience after licensure was required under these agreements.18

A certain irony can be found in the early success of the reciprocity/endorsement movement. In 1904, 27 states had “reciprocal relations” with other states; by 1922 the number had risen to 44 states. State boards had moved aggressively to facilitate licensing physicians seeking to relocate between jurisdictions. However, broad remedies developed by boards to facilitate license portability seemed to be matched equally by an array of complicating factors. One was the discrepancy in the quality of the medical education of prospective licensees. Medical education reform in the early 20th century could not account for the vast number of previously licensed physicians whose educational credentials from inferior schools predated this period. More distressing was the experience of state boards in dealing with issues of moral character. The practical experience of boards soon taught them the numerous ways that dishonest candidates could circumvent the system. Imposters sitting exams, frauds assuming the identity of licensed physicians and frequent relocations one step ahead of local authorities provided every state board with cautionary tales. Administrative procedures calling for personal appearances before the board, “advance filing” of the endorsement licensure application and duplicate photographs became commonplace as mechanisms for combating deception. The lesson being absorbed by state boards in the 1920s was clear: There was more to fear from the small number of practitioners with poor character and good education than the more numerous physicians with a lesser education but solid moral character.19

Discipline

The volumes of the Federation Bulletin underscore the significant challenges facing state boards as they sought to regulate the practice of medicine. Although the Bulletin included news items that alerted readers to criminal convictions against physicians and subsequent actions taken by the board against such individuals, this was widely recognized as insufficient. What most frustrated the licensing community was the knowledge that information on physicians of “questionable character” was too often inaccessible and buried in another state's records.20

Boards desperately needed a “central bureau” to serve as a clearinghouse for information about practitioners. Unfortunately, limited resources and a prospective cost in excess of $3,000 annually left the Federation convinced that it was not yet able to undertake such an initiative. Instead, the Federation formulated an arrangement with the Biographical Department of the AMA. State boards were encouraged to make routine, systematic reports to the AMA Biographical Department on frauds, imposters, criminal convictions and “all official actions” taken by the boards and to provide photographic copies of their applications and physicians' photographs. Such measures occasionally bore fruit but were generally ineffective.21

Another challenge facing state boards arose from a more fundamental level. Not all state legislatures had codified the disciplinary function of their medical board. For example, in Virginia the state board lacked authority to revoke a license until after 1910, nearly 25 years after the board's creation. It was only later in the 20th century that the disciplinary and regulatory functions of the boards came increasingly to the forefront. In the first decades of the 20th century, state boards repeatedly faced disinterest, non-cooperation, and sometimes even opposition, from both local courts and the public in seeking to regulate the practice of medicine.22

This lack of support can be seen in boards' experiences with pursuing cases involving illegal practitioners. A 1919 Federation survey of state boards showed that only 14 states saw any significant activity in prosecuting such cases, with most of these centered in Illinois, California, Pennsylvania, Indiana and Ohio. Until 1921 North Carolina's medical practice act contained a “fee and reward” clause such that the board had to prove not only the unlicensed practice of medicine but that the individual had received compensation for his or her services. For boards, dogged persistence was necessary to interest the average local prosecutor to collaborate in prosecuting and shutting down unlicensed practitioners.23

State boards began looking more critically at their disciplinary and enforcement functions, starting with their medical practice act. Too often legislation in this area was “piecemeal” rather than a single piece of overarching legislation. The resulting legislation was sometimes almost “unenforceable,” with physician misconduct handled at the local level by county or state medical societies, when it was addressed at all. Even long established boards, such as that in North Carolina, did not benefit from updated legislation that clearly defined the practice of medicine until 1921. In other instances (e.g., California), the medical board spent much of its early energy defending its legal status as the entity authorized to regulate the medical profession.24

Of necessity, state medical boards in the 1920s were learning the importance of their procedural processes for medical discipline. Some state boards grew savvier in structuring their meetings along more legalistic lines for dealing with disciplinary matters. Some took appropriate measures that allowed for “degrees of punishment” such as reprimand, probation and suspension rather than recourse to a draconian revocation. Procedural safeguards for due process not only ensured fairness and equity for the licensee but provided a solid defense for the board's action should it be tested within the courts system.25

Developing appropriate investigative mechanisms proved critical for state boards grappling with the problem of individuals seeking a medical license by fraudulent means. While such cases continued to plague the system, far more troubling were the “diploma mills” still operating during the 1920s. Several questionable medical schools operated throughout the country, including the Kansas City College of Medicine and Surgery (Missouri). That school's operations led to major investigations and harsh criticism of state boards in several states. A 1923 St. Louis Star exposé tracked some of the school's graduates to the Connecticut Eclectic Board of Medical Examiners whose standing with the public proved irreparably damaged by revelations that advance copies of their licensing examination were delivered to the school to prepare candidates. Licenses for 175 physicians were revoked and a “vigorous housecleaning” soon followed that replaced the entire eclectic board.26 Similar repercussions fell upon the Missouri board. Extortion and “influence” by the school with a member of the medical board supposedly sufficient to keep one of the school's graduates from appearing before the board created major news headlines. The governor removed most of the board, retaining only three members who had been diligent in pursuing the investigation.27

A widely circulated report on the scandal turned an unsparing eye on the eclectic boards in Arkansas and Connecticut. The report attributed much of these boards' failure to their examination processes — specifically, inadequate proctoring during the licensing examination; frequent reuse of questions on their examination; and overly “generous” exam scoring. The Arkansas eclectic board was also harshly criticized for its persistence in licensing graduates of the school well after the scandal broke.28

The Federation used this unfolding drama to advocate for specific practices, including a renewed call for a single board of medical examiners in each state. The Federation also encouraged all states to reconsider their practices for appointment to state boards. Specifically cited were practices such as excluding medical educators from appointments or blatant political appointments without regard to qualifications.29 The diploma mill scandal underscored the need for continued vigilance on the part of state medical boards. Meanwhile, in the field of medical education, the Federation and state medical boards enjoyed the fruits of reform measures begun earlier in the century.

State Boards and Medical Education

The licensing community's interest in medical education dates back to the 19th century and the work of John Rauch in Illinois. State boards made significant progress in mandating higher standards for education that were consistent with the reform efforts of progressive medical schools committed to a model of academic medicine. Yet much work remained to be done. Abraham Flexner's 1910 report on medical education in the United States devoted an entire chapter to state medical boards and their role in facilitating quality medical education. Flexner and others recognized that state boards alone possessed the legal authority to secure higher standards for medical education and deny licensure to graduates from substandard schools unwilling or unable to implement such standards. According to Flexner, the licensing examination was the great “lever…[by] which the entire field may be lifted.” Furthermore, limiting access to the examination “only after a fair presumption of intellectual fitness…has been established” served a similar salutary function. The medical licensing community must have been gratified by Flexner's strong assertion that final improvement in medical education would derive “from control of all schools through the state boards.”30

The Federation spent considerable energy on this topic, continuing the work of its predecessor organizations. In the span of a single generation, state boards helped transform medical education through mandated higher standards as requirements for licensure. In 1904, only 10 states required a high school diploma as a requirement for a license and no state required college course work. By 1929, 43 states mandated 1–2 years of college course work in addition to the high school diploma. Additionally, 14 states required a one-year hospital internship after medical school.31

The complementary efforts of the Federation, state medical boards, the Association of American Medical Colleges (AAMC) and the AMA Council on Medical Education wrought major improvements in the quality of the medical education. While much of the impetus for reform came from the many progressive schools, the reality remained that many proprietary schools were not receptive environments for reform. Only the “regularizing influence” of the AAMC and the AMA working in concert with the statutory mandate of state medical boards allowed the reform movement to achieve its goals. The number of Class C (or after 1928, “nondescript”) medical schools dropped from 23 in 1913 to six in 1932. Class A schools that once accounted for only half of all the medical school graduates in 1918 accounted for 87 percent of all graduates by 1929. Where once only 31 medical schools were recognized by all state boards (1914), 70 schools enjoyed such recognition by 1927. The boards' focus on bringing inferior schools up to minimum standards carried an almost moral imperative. Unlike 50 years earlier, the education and training of a physician did matter in terms of patient outcomes.32 The public protection function envisioned for state medical boards' necessitated their involvement even if that role was largely one as the regulatory hammer extracting the last few rusty nails among the planks of medical education.

At the close of the 1920s, discussion between the medical education and licensing communities shifted toward avoiding “duplication” in overseeing medical education and avoiding overly detailed and inelastic state requirements that hampered curricular changes. Even well-intended standards could prove counterproductive at times as evidenced by the Pennsylvania board's 1914 directive to Tufts medical school that it would no longer examine its graduates if the school continued admitting students “on condition.” This despite the fact that Tufts was rated as a Class A school by the AMA Council on Medical Education in 1913.33

Clearly, the vigilance necessary to foster improvements in medical education during the earlier years of the 20th century was now less critical. Identifying the appropriate accrediting body to set standards seemed now the more appropriate means for ensuring quality. The Federation agreed, as evidenced by a 1929 resolution adopted by its membership, calling for revisions to their medical practice acts that “conform[ed] as far as possible with the principles” of the AAMC.34 Consensus was not always so easily achieved in other areas.

Professional Tensions and Basic Science Laws

At the turn of the century, professional identity and economic self-interest were significant pressures on the medical profession. Physicians saw the former as critical to a formalizing profession. Critics saw the latter motivating physicians feeling threatened in the marketplace. These tensions spilled over into the medical licensing community.

After World War I, the number of international medical graduates (IMGs) presenting themselves for licensure increased. State boards examined fewer than 100 IMGs annually between 1917–1920 before a sharp increase to 500 annually in 1924–25. America's post-war atmosphere had changed markedly. A heightened sensitivity to political radicalism impacted both the Federation and state boards. Language such as “alien invasion” and “influx of undesirable foreign applicants” crept into the Federation Bulletin's editorials.35 Meanwhile, state legislatures amended their medical practice acts to include U.S. citizenship as a requirement for licensure. By 1926, 11 states had such a requirement and 15 others required naturalization papers or a declaration of intent to be filed. Some state boards (Michigan, New York) required a year's work in a U.S. medical school or a hospital internship year (Pennsylvania).36

More significant tensions arose from the different practitioners treating patients in some form or fashion other than what was deemed traditional medical practice. Here the passions grew more heated. Just as an earlier generation of physicians argued against cooperation with homeopathic and eclectic counterparts, physicians on state medical boards now cast a wary eye toward osteopathic physicians, chiropractors, Christian Scientists and “drugless healers.” Critics faulted these groups for alleged inadequate education/training and a tendency to stray outside their system to include treatment options (e.g., administering drugs) that fell under the statutory definition of the practice of medicine. The Federation identified this tension as the “most important problem” facing state boards in 1917.37

These tensions were hardly new. In the late 19th century, physicians were often differentiated as homeopathic, eclectic or ‘regular,’ with many states maintaining separate boards for each. By the 1920s the profession had integrated and subsumed homeopathic and eclectic physicians under the commonly shared mantle of MD. The animosity now directed toward osteopathic physicians, chiropractors and others was noteworthy only for the vehemence of the attacks. Disparaging terms such as “cults” were assigned these groups with the harshest language reserved for the chiropractic community and Christian Scientists.38

Osteopathic physicians encountered significant opposition within the medical profession but were making progress in gaining professional independence. Vermont was the first state to license osteopaths in 1896, with 14 more states doing so by 1901. Extending state licensing privileges to osteopathic physicians, however, did not always mean the general unrestricted medical practice they desired. Some states issued limited licenses that restricted the scope of practice of osteopathic physicians. In 1903, Michigan became the first state to extend “unlimited practice rights” to osteopathic physicians. By 1929, 15 states enacted similar laws. Such progress was offset by setbacks such as the military's opposition to commissioning osteopathic physicians in the Army and Navy Medical Corps during World War I.39

Approximately 17 states provided for a separate osteopathic medical board during that same time period. The osteopathic experience in states where a single composite board had members representing multiple ‘systems’ varied markedly. In some instances, the board modified its licensing examinations accordingly for osteopathic candidates (e.g., dropping materia medica questions). In other states, the results were different, such as in Iowa, where the board refused to accredit any osteopathic medical schools.40

Some individuals hoped to curb the inflammatory language. Federation President David Strickler sounded a conciliatory tone in 1917 by acknowledging that the intent of many individuals pushing for a single examining board in each state was to “eliminate the sectarian” physician. He championed making room within the profession for those willing to ensure adequate education and training for practitioners and condemned the “vindictive spirit” prevalent in the profession. His pragmatic call for a “clinical study of [those] systems of healing” already enjoying public support and/or recognition drew favorable comment from the AMA, the American Osteopathic Association, the American Institute of Homeopathy and the AMA Council on Education. Before the proposal could gain traction, however, independent initiatives in Wisconsin and Connecticut channeled discussions in a new direction.41

In 1920, Wisconsin enacted legislation requiring an examination in the basic sciences for all persons practicing the healing arts. The impetus for this proposal stemmed from turf wars between the state's physicians and chiropractors, leading to the first basic science law in 1925. Until their demise nearly 60 years later, independent boards assessing candidates in the basic sciences would appear in 23 states and administer 150,000 examinations.42

Wisconsin's law sought to protect the public against ignorant and unskillful practitioners whatever their training. The state established a basic sciences board (composed of educators unaffiliated with any of the healing arts) to test candidates in four areas: anatomy, physiology, pathology and diagnosis. Anyone treating the sick would have to pass the basic science examination and present this credential to the respective licensing board (e.g., medical, chiropractic). The licensing board could then accept this credential in lieu of further examination in these basic sciences as part of its licensing requirements.43

This model soon spread elsewhere. Connecticut enacted a similar law later in the same year, though primarily in response to the diploma mill scandal that tainted that state's eclectic board. Eight states followed suit by the early 1930s. The composition of these boards usually followed the Wisconsin model, though when membership drew from the respective fields of practice, they usually placed an equal number of representatives for physicians (allopathic and osteopathic) and chiropractors.44

The Federation struggled in identifying an appropriate response to this trend. It belatedly opposed these boards, fearing they would make permanent the division of licensing boards within these states — a reality inconsistent with the organization's position supporting a single board of medicine. Additionally, pass/fail statistics on the basic science boards seemed to indicate these examinations represented a major hurdle to the non-MD physicians taking them. Far from advantaging the interests of these other practitioners, the basic science laws appeared to set a minimum standard that many struggled to meet. Additionally, the introduction of these examinations added yet another variable into the licensing system.45 The persistence of these examinations for decades to come meant that state medical boards were saddled with an unevenly adopted requirement that did little to foster the uniformity in standards.