Part 6: Regulation of Medical Practice and Schools in the United States.

On May 27, 2010, I posted a blog concerning medical training in the United States before the 20th Century. In that blog, I mentioned that as early as 1732, I found complaints about the lack of regulation and licensing of doctors. As I researched the history of medicine in the United States, I found that there was no overall regulation of the practice of medicine until the 20th Century.

There was very little regulation in the British North American colonies. Although regulatory powers traditionally were given to the legislatures of the provinces, it was the professional societies that initiated regulation of medical practices. The first organization of medical professionals was chartered July 23, 1766 in the Province of New Jersey. The New Jersey Medical Society was established to develop a code of ethics, fee schedules, education standards and regulation of medical practice.

When the United States Federal government was formed, regulatory powers for the most part remained in the hands of the states. The state of New York in 1806 legislated licensing but only for the purpose of allowing licensed medical practitioners to sue in court for the recovery of fees. Attempts by other states to regulate medicine were repealed because public sentiment bristled at the thought of government control. By the early 1800s, medical practice regulation was firmly in the hands of the medical societies and by 1850 only three states and the District of Columbia had licensing regulations.

One would think the fact that the medical societies had instituted licensing regulations was adequate. However, there were different types of medical practices that were recognized including homœopathy, allopathy, herbalism, etc. Each had its own medical societies and each medical society defined its own regulations and guidelines. Competition in the medical field was intense and practitioners resorted to many means in order to compete that included ignoring regulations set by their societies.

Dr. Nathan S. Davis, instrumental in the creation of the American Medical Association, in 1845 commented on page 418 in the Journal of Medicine concerning the lack of thorough training and education acquired by students of medicine. However, the real force in the founding of the AMA was the fact that doctors in order to compete in the free market made little money.

A national convention of physicians was held in 1847 and on May 5th the delegates established the AMA. Dr. Davis' complaint concerning the educational standards was addressed and for the first time a medical student was required to have clinical experience at a hospital. The AMA also defined requirements that a prospective student meet in order to be admitted to a medical school. The AMA strengthened the standards in 1852.

However, even by the 1870s many medical schools were not equipped with laboratories nor its own hospital. Johns Hopkins University decided to create a model school of medicine. In 1893 the School of Medicine opened with well-equipped laboratories and its own hospital. As universities overhauled their medical programs, many medical schools with inadequate facilities closed.

Between the establishment of the AMA and the creation of the medical program at Johns Hopkins University, by 1900 quality of medicine had vastly improved for patients.

Sources:
U. S. National Library of Medicine, www.nlm.nih.gov/medlineplus/ency/article/001936.htm.

Wellness Directory of Minnesotat, www.mnwelldir.org/docs/history/history03.htm.

Francis Randolph Packard, M.D. The History of Medicine in the United States. Philadelphia: J. B Lippincott Company, 1901.

Nathn Smith Davis, M.D, LL. D. History of Medicine with the Code of Medical Ethics. Chicago: Cleveland Press, 1907.

Part 2: MD with an LLD Degree or Is It LLD with an MD Degree?

I created a spreadsheet from the information included in Walter Eliot's book, "Portraits of the Noted Physicians of New York 1750-1900." Then I found other sources including the Journal of the American Medical Association, the New York Times, etc. to fill in the information missing from Walter Eliot's book.

The physicians included in the book were in most cases on the faculty of medical colleges primarily in New York. Some were medical directors of hospitals, while others authored books on a particular area of study. A few invented things of significance in the health care arena of the 19th century.

All of the physicians who obtained an LL. D. degree did so after earning the medical degree. However, all of these doctors continued in their pursuit of medicine after earning the law degree. Most of these doctors earned the law degree twenty years or more after receiving the medical degree. Nearly three quarters of the doctors earned the law degree between 1878 and 1899.

I find it very interesting that so many of these physicians were awarded an LL. D. degree in the 1890s. I do not know why but will see if I can find an explanation. Curiosity is getting the best of me. I am very interested in seeing if practicing physicians during this period who were not affiliated with a teaching school were getting LL. D. degrees as well.

What was the average age of these men when they earned their medical degree? My spreadsheet included the birth year as well as the year in which each earned his M. D. It was easy to add a calculation that provided me with the age  of each of the 199 men at the time each received his M. D.

The youngest was 19 years old. Most obtained the medical degree between the ages of 21 and 26. The peak age was from 22 through 24 years. These three ages represents 50% of the doctors in the book. The men who obtained an M. D. age 21 through 26 years of age represent 82% of all the physicians included in the book.

Things have changed from the 19th century to the latter part of the 20th century. I don't have the numbers but I have observations from having worked in the Bio-mathematics Department of the School of Medicine at UCLA in the late 1970s and observing my daughter and her medical school colleagues more recently/ It appears that most doctors receive the M. D. at age 26 years.

The physicians included in the book had areas of specialty for which each was noted. However, from what I have ascertained in my research, formal residencies that the current medical student face before being allowed to practice in a specialized area did not appear to exist during the period covered by the book. Working with a preceptor seems to be the way in which MDs in the 19th century entered specialized practices.