The History of the Federation of State Medical Boards: Part Three — Federation Resurgence, 1930–1959

Indicators and Contributing Factors to an Organizational Lull

Perhaps the most surprising indicator of such relative passivity was the absence of special committee activity over much of this period. Earlier, the Federation made extensive use of special committees to address a variety of issues. Yet after the Federation's participation on a committee dealing with medical education in 1934, no special committees were formed until 1946, when it established one to “better integrate” the activities of basic science and medical licensing boards. No special committees of lasting importance were constituted until the 1950s with the Special Committee on Uniform Licensure Laws (1952) and the Special Committee on Examination Institutes (1956).2

Symptoms of organizational malaise could also be found in the content of the Federation's annual meetings and its monthly Bulletin. A small number of topics, or variations upon them, came to dominate the content of the annual meeting, e.g., international medical graduates, licensing exams, basic science boards, etc. All acquired a certain staleness stemming from attendees' prolonged familiarity with the subjects. Presenters inherited the unenviable task of trying to impart a new twist on a recurring list of thorny issues.

A similar narrowing of focus can be seen in the Federation Bulletin, which continued as the primary communication tool linking the Federation to its membership. The Bulletin devoted increasingly more space to medical education and issues broadly relevant to the medical profession as a whole compared to the more specialized issues surrounding licensure and discipline. Issues impacting medical education and the medical profession, while relevant to medical boards, appeared with such disproportionate frequency in the Bulletin that one senses a developing insufficiency in focusing on the issues and problems unique to medical regulators.

There was another small but telling indicator as well. Over the course of nearly a century the Bulletin occasionally carried presidential addresses or historical articles looking back at the Federation's past. These presented rich, detailed material on the first decades of the organization; yet almost invariably these pieces devoted little or no space to the 1930s and 1940s. The retrospective silence hovering over these years seemed a tacit acknowledgement of fewer tangible accomplishments comparable to those witnessed in earlier and later periods.3

These indicators do not, however, explain what caused this organizational lull. One can only speculate, but four factors seem to have been at work. One of the more obvious was the impact of national and international events on the Federation and this country's medical regulatory system, specifically the Great Depression and World War II. Aspirations for organizational growth depended heavily upon increasing its financial resources. At that time, the Federation lacked a revenue-generating product or saleable service for its membership. Thus, the Federation relied upon member dues as its primary means of revenue. As the nation did not emerge fully from the Great Depression until 1939–40, the Federation had little choice but to keep its annual dues static. That occasionally member boards were in arrears on these relatively low dues ($25) underscored the depth of the economic woes plaguing states.4

Even as the country regained its economic footing in the early 1940s, the U.S. entry into World War II meant that national and international events shaped the issues facing the Federation and state medical boards. Now workforce issues such as physician preparedness for active duty military service and later their re-integration into the civilian sector moved to the forefront, while the more traditional issues that the Federation and its membership had grappled with previously such as disciplinary processes and licensing examinations ceded the center stage.

A second related factor may have been the scale and complexity of the problems confronting the nation in the 1930s and 1940s which seemed beyond the capacity of individual states.5 To some Americans, the urgency of the national situation served to legitimize the appropriateness for a large-scale federal response to certain issues. The public's perception of voluntary associations and state government as inadequate to address large scale socio-political issues had crystallized with the Hoover administration's failed immediate relief efforts in the early 1930s. It seems possible the Federation leadership slipped unconsciously into a reactive mode, ceding the initiative for addressing regulatory problems to larger professional organizations and the federal government.

A third explanatory factor falls under the broad heading of leadership. Here there are two salient points to be made. In 1924, the Federation revised its bylaws to accommodate the annual selection of a president-elect for the organization. In shifting to a time-specific tenure for elected leadership (one year of service as president), the Federation broadened the base of its participants in leadership. This contributed to a greater sense of inclusion by state medical boards and a stronger collective vested-interest in the outcome for initiatives. Yet, this may have been offset by a loss of continuity in senior leadership responsible for multi-year initiatives. Organizational planning oriented itself around the one-year tenures of elected presidents. There is another important point to be made about leadership — the potential for complacency. Many state board leaders of this era enjoyed long tenures on their board, which may have fostered a high degree of self- assurance arising from having firsthand experience with the immediate issues facing the licensing community. Without realizing it, long-tenured board members may have succumbed to complacency over time. These elements contributed to a leadership cadre during the 1930s and 1940s that lacked the dynamism seen earlier.

A final factor behind the lull characterizing the Federation during this era is admittedly more speculative. Organizational theorists have applied a life-cycle metaphor to business entities — stating that all organizations are constantly engaged in activities that either hasten toward a theoretically inevitable decline or reinvigorate the organization in ways that maintain a prolonged period of growth and maturation. By the end of the 1940s, it seemed the Federation passed from “inception” to a limited maturity beyond which it could not grow without major organizational changes. At the time it was unclear what the future held for the Federation. By the mid-1950s it was clear that further growth and renewal remained before the organization.

A Model Medical Practice Act (MPA)

The first major accomplishments during the Federation's 1950s resurgence came in an unlikely area — the development of a model Medical Practice Act. This long-sought goal had languished for decades as an issue on the agendas of the Federation and the nation's medical boards. Little legislative progress had been made for decades. One reason for this may be inferred from the seemingly innocuous comment of one board's secretary who stated, “I am a believer in men more than in measures.” In expanded comments, the secretary called for delegating the details of board administration to strong, “qualified” members, providing them with wide latitude and broad discretionary power, and resisting overly detailed protocols that might limit the board. If these comments were typical, then board members cast an inherently wary eye toward legislative remedies as the final solution to any and all problems. Thus, the desire for greater uniformity in medical regulatory legislation did not outweigh concerns that overly prescriptive laws might restrict their discretionary authority. Additionally, state medical boards recognized that turning to the legislatures to resolve outstanding issues required a willingness to distinguish between the legislatively “practical” and the theoretically possible. For some this meant a preference for informal ad hoc solutions rather than risking statutory outcomes worse than the original problem. Such sentiments, when combined with an acknowledged understanding that success in this area would come only after a protracted period of “discussion and study,”6 resulted in little progress for decades.

In 1952, Federation President John McCann (Ohio) established a Special Committee to Draft a Uniform Medical Practice Act. The committee made a “comprehensive study” of all medical practice acts to identify “essential or basic requirements” that should be present in all iterations of such legislation. The committee drew assistance from AMA legal staff to review all medical practice acts and undertook extensive surveys of medical regulators and educators. In 1954, the committee shared preliminary findings which including a handful of commonalities: the existence of a state agency overseeing medical practice; requiring graduation from an approved medical school (applicable to U.S. graduates); passing a qualifying examination; and some methodology for revocation of a license. Beyond this, little statutory uniformity existed with variance in the requirements for licensure (e.g., internship, citizenship); exam content; and bases for license revocation proving the norm.7

Despite the variances, the committee remained hopeful as the true “extent of the lack of uniformity” was not fully appreciated because state boards had so “ably administered” within the allowable scope of their laws. In essence, able administration had wrought “a large measure of practical uniformity.” Buoyed by this acknowledgement and the labor already invested in the initiative, the committee crafted a document to serve as a “guide” to inform each state's medical practice act. The committee gradually came to the realization that while a “uniform” Medical Practice Act might be impractical, it was still possible to identify the “essentials” of one that could serve as a template.8

Their efforts bore fruit in 1956 with A Guide to the Essentials of a Modern Medical Practice Act. The modestly titled volume culminated several years of effort and more than forty years of discussion. The report distilled a series of recommendations that addressed five core areas: the definition of the practice of medicine; eligibility standards for licensure; licensing examinations; licensure endorsement; and the bases for probation, suspension or revocation of a license.9

Since its initial publication in 1956, the Essentials has passed through multiple updated editions. The purpose behind the Essentials has been two-fold: (1) to guide states in revising or writing anew their MPA and (2) to encourage the use of consistent standards, language and definitions in their statutory language. The Essentials has become a living document frequently referenced by state boards as a template and tool in drafting their state statutes or board's rules. Tim Miller, former executive director for the Arizona Medical Board, speaks glowingly of the Essentials' practical utility. In his experience, the Essentials alleviated the need for his board to “reinvent the wheel” in crafting language anew but “built credibility with legislators” when proposed changes carried the imprimatur derived from model language developed by a national organization representing all medical boards.10 By virtually any standard one might apply, the Essentials document has proven an invaluable resource and a sturdy workhorse for state medical boards. Whether being used to revise statutory language or as leverage against balky legislators, Essentials has proved to be perhaps the single most successful policy document of the Federation.

State Medical Boards and International Medical Graduates (IMGs)

For many years, state medical boards struggled with how best to evaluate and assess the credentials and preparedness of international medical graduates seeking training and/or licensure in the United States. In the mid-1950s, the Federation engaged in collaborative discussions and initiatives designed to alleviate these concerns. The Federation's contributions in this area came only after many years of difficult, even contentious, dialogue at the intersection of sometimes conflicting interests among the licensing community, the medical profession and international medical graduates.

To fully appreciate the landscape of medical licensure in the 1950s and the position of IMGs, it is necessary to first consider developments over the preceding decades. The situation confronting émigré and refugee physicians seeking to practice in the United States on the eve of World War II resembled a perfect storm of obstacles. Federal law had imposed quotas on the number of allowable immigrants since 1924; subsequent citizenship requirements imposed for a medical license raised separate state-specific hurdles. The economic conditions of 1930s America left medical professional groups opposed to measures that would increase physician numbers and potential competition. Lingering “nativist” biases rounded out this mix of powerful oppositional forces confronting IMGs.^*

Wartime disruptions of travel and education meant that, émigré and refugee physicians aside, the number of IMGs voluntarily seeking additional medical training in the United States had diminished. This reality did not last long. In 1948, American hospitals were expanding with the start of the baby boom after the return of hundreds of thousands of veterans. However, there were not enough U.S. medical school graduates to fill all the internship and residency positions available. A substantial number of U.S. graduates chose other paths (e.g., military, research, public health service) and bypassed hospital training. By 1953, international graduates accounted for an estimated 5,500 interns and residents in the United States. Two years later the number was documented at slightly more than 6,000. Of the 7,000 hospitals in the United States looking for interns, only 1,300 were said to have approved education programs connected with them.11

State boards now faced an unprecedented number of international medical graduates. For those boards that did not unilaterally preclude IMGs from licensure, these physicians presented significant challenges in terms of verifying credentials and drawing reasonable, informed conclusions as to their preparedness to treat patients safely. By 1949, 27 state boards licensed interns and/or residents; thus, issues of access to, and qualification for, internship and residency positions were ones fully within the domain of state boards. These same boards and other interested organizations increasingly looked to the Federation to see if guidance toward a national solution would be forthcoming. In early 1949, discussions began in earnest with the meeting of an informally constituted Committee on Foreign Medical Credentials. Representatives from the Federation as well as the Illinois, Minnesota, New York and Wisconsin medical boards were in attendance, along with 14 other organizations, institutions and foundations and the U.S. State Department. The committee condemned administrative and statutory restrictions that resulted in “complete exclusion” of IMGs while also affirming the responsibility of state boards to obtain adequate information about the quality of these physicians' medical schools and thus the education they had received. The group recommended a multi-organizational pooling of resources to investigate and gather information supporting a list of medical schools “comparable” to U.S. schools. Formal standards to ensure comparability of U.S. schools had been set in 1942 with establishment of the Liaison Committee on Medical Education (LCME), the sole accrediting authority for medical school programs in the United States issuing the MD degree.12

Acting as de facto accrediting agencies, the AMA Council on Medical Education and Hospitals and AAMC had long provided the evaluative and informational bases for determining ‘approved’ medical schools in the United States — a listing that state boards had come to accept and rely upon. Now the two organizations prepared to expand their periodic surveys and evaluation of medical schools to those outside of the United States. A preliminary listing of approved international schools appeared in early 1950. As for the schools not listed, the Federation tackled the question of how state boards should deal with these schools' graduates in a February 1951 resolution calling for all graduates of schools not on the approved list to complete two years of additional medical education in the United States or Canada before being allowed to sit for a medical licensing examination.13

Rather than proving to be a definitive solution, the insufficiency of these measures soon became apparent. A mechanism for assessment predicated upon a list of approved schools was inadequate for the large number of IMGs seeking graduate training and/or medical licensure in the United States. There were simply too many physicians from schools for which information was lacking. At an April 1954 conference with twenty-two participating organizations, a Federation proposal presented the group with a strategic change in course: evaluative efforts should shift from evaluating schools to evaluating individual candidates. This shift was consistent with a unique approach to assessment of IMGs being utilized by the Michigan medical board at the time. An “oral screening board” composed of medical educators from the states' two medical schools conducted oral examinations in basic and clinical sciences. Passing candidates received a temporary license to begin serving an internship in an approved hospital. Failing candidates for whom English seemed to be the source of difficulty were provided access to language courses.14 The suggested proposal by the Federation in 1954 built upon the Michigan experience to utilize a “central screening agency” to evaluate credentials and assess preparedness before allowing the physicians to begin an internship and then sit for a licensing examination. The Federation returned with a formal proposal for a “joint commission” that was accepted in principle by the AMA Council on Medical Education, the American Hospital Association and the AAMC. Soon thereafter the four organizations established a “Cooperating Committee” on Graduates of Foreign Medical Schools. The Cooperating Committee recommended that a separate organization be established to receive applications from IMGs, verify their credentials and administer a preliminary examination. Passage of this preliminary examination would allow the physician to enter into an internship and subsequently sit for a state board licensing examination.15 In 1956, the resulting organization was established: the Educational Commission for Foreign Medical Graduates (ECFMG). Since 1958, more than 300,000 physicians have gained ECFMG certification qualifying them to enter into graduate medical education in the United States.16

The Federation's collaborative role leading to the creation of the ECFMG offered a second major success for the organization in the 1950s. With a growing sense of momentum building around the organization, the Federation in 1956 tackled perhaps its biggest challenge — bringing greater uniformity to the nation's medical licensing examinations.

Examination Institutes — Collective Improvement in Assessment

In 1956, the Federation embarked upon perhaps its most ambitious initiative to date. State boards had long been aware of growing deficiencies in their examinations. Critics pointed to several problems: examination content that varied widely between jurisdictions; outdated test items; and differences in scoring leading to the application of an uneven standard for minimum performance. Even sympathetic medical educators lamented the examinations as often duplicative of their educational testing and out of step with curricular innovations. The Federation understood that these problems diminished the prospects for meaningful progress on endorsement licensure by undermining the potential for licensing examinations to serve as the common standard upon which all endorsements might rest.

Inspired by recent collaborative initiatives in medical education, Federation President McKinley Crabb (Texas) urged state medical boards to undertake a major, collective effort to improve their examinations. In February 1956, Stiles Ezell (New York) introduced a resolution calling for the Federation to establish a “permanent committee…to develop and activate examination institutes in the major branches of medicine...for the purpose of creating uniformity in content and quality” of medical licensing examinations. With the approval of the resolution in that same year, the Federation selected Ezell to chair a Permanent Committee on Examinations which included Sam Poindexter (Idaho), Frank Peterson (Iowa), Andrew Gehret (Delaware) and Harold Jervey (South Carolina).17

The Permanent Committee developed a proposal modeled upon the AAMC's experience using teaching “institutes,” each oriented around a specific subject matter. These national gatherings (1951–1953) had resulted in an evolving document that set forth the educational objectives for teaching in U.S. undergraduate medical education. The Federation sought to duplicate this model and apply it to the construct and content of the nation's medical licensing examinations. Each one in the series of Institutes would draw upon individual members of state boards selected to identify the major concepts and content for assessment in a given subject area routinely included on licensing examinations. At the first planning meeting of the Permanent Committee for the Examination Institute, the following objectives were identified for the institutes:

1. Promotion of uniformity in licensing examinations

2. Establishment of equivalent levels in examinations

3. Improvement in the quality of examinations

4. Creation of a rational basis for endorsement

5. Placement of licensure in a definite relation to modern medical education

6. Assistance for state boards in assessing international medical graduates

The Federation and the Permanent Committee made clear that the endeavor was not intended to “challenge or criticize” the work of the National Board of Medical Examiners. The latter, however, had recently decided in 1954 against admitting IMGs to its certification program; thus, the assessment of this sizeable cohort fell squarely upon the shoulders of the Educational Commission for Foreign Medical Graduates (ECFMG) and state medical boards. A supportive National Board acknowledged the Institutes as necessary exercises in self-improvement for state boards.18

Perhaps the most critical idea to come from the Committee's planning session was the concept of “fitness to practice” or “fitness testing.” Here the committee attempted to delineate, a clear distinction from the “educational testing” conducted by medical educators. With the disappearance of unapproved medical schools in the United States, state boards had far less need to worry about testing in the domains inhabited by medical educators (e.g., basic medical sciences). State medical boards could instead focus on the clinical application of medical knowledge with patient-centered questions that posed a problem requiring the licensure candidate to demonstrate the ability to transfer theoretical knowledge into diagnosis, treatment and patient management. Fitness testing represented a significant philosophical shift in the written questions utilized by most boards.19

The Permanent Committee proposed convening a series of Institutes over a three-year span and covering the following major areas: Anatomy; Physiology; Pharmacology; Biochemistry; Bacteriology; Pathology; Hygiene and Public Health; Surgery; Obstetrics and Gynecology; and Internal Medicine. State boards were encouraged to allocate funds to support member participation with the goal that each Institute would convene a minimum of twenty participating members from across the country. The committee would draft a “master plan” for each Institute, identifying the objectives for each session with the goal of a final report outlining the content areas and construct for an appropriate examination in each area. Institute participant would then return to their respective boards charged with carrying on the work of revising their board's examination to align with the content outline developed through the Institute. Through this method, the Federation hoped to jump start a collective “self-improvement” initiative that would raise the quality of licensing examinations nationwide.20

The first Institute took place in 1957. The work of this first Institute was representative of all that followed. Attendees were led through a series of questions designed to elicit how testing oriented toward fitness to practice should manifest itself in the construction and outline for examination content. Attendees then considered where licensure candidates fell on the educational continuum as a means for identifying appropriate content coverage, bridging the gap between assessment being conducted for medical students and interns as opposed to the “highly specialized” knowledge and skill set being assessed by the specialty certification boards. In this regard, the attendees sought to identify the inherent level of “responsibility” vested in the physician by virtue of the medical license; having done this, the attendees then attempted to outline the corresponding parameters for testing in that clinical area.21

The inaugural 1957 Institute on Obstetrics and Gynecology proved successful. Its attendees concluded that it was possible for a licensing examination to “confront the candidate with a [patient-centered] problem situation involving the use of responsibility and judgment . . . which requires evidence of a methodical approach and a logical conclusion.” Subsequent Institutes followed in 1958. Stiles Ezell articulated the significant challenge that the Institutes posed to the individual state board examiner. These physicians were required to think deeply about the construct of their examinations and view them as dynamic instruments requiring boards to maintain some degree of currency in both medical knowledge and the emerging science of assessment. This posed a considerable challenge. In essence, state boards were confronted with a responsibility for “self-improvement” to justify their continued assessment role in medical regulation. According to Ezell, the changing times and a modern regulatory system required that state medical boards offer “more logical reasons for existing and more stimulating purposes than self-perpetuation.”22

The Federation conducted nine Institute workshops by the end of the 1950s. The organization's leadership remained cautiously optimistic that their labors in this area might rapidly bear fruit. The Federation Bulletin stated bluntly that “if there is not a marked improvement in examination construct [by next year], there may…not be any at all.”23 As it turned out, by the 1960s a variety of factors forced the state board community to make difficult decisions about their continued role in the assessment arena.

This cautionary note did not alter the importance of much that had transpired with the Federation during the 1950s. The organization had succeeded in reversing course from a protracted period of lesser accomplishments in the 1930s and 1940s that threatened to leave it irrelevant. The major initiatives of the 1950s (Examination Institutes, the Essentials, establishment of the ECFMG) signaled a resurgent Federation. These initiatives demonstrated the ability of the Federation to coordinate dialogue among the nation's state medical boards, assist them in reaching consensus on major issues and then help implement changes that benefited the entire state-based system of licensure. While much work remained to be done on a multitude of fronts, the Federation leadership could enter the 1960s appropriately optimistic for the organization's future. The achievements of the Federation in the 1950s signaled growth, rather than decline, as the immediate future direction of the organization.