Lecture Five: The Origins of the AMA

With orthodox medicine in disarray, with no standards of education, and with alternative medical philosophies ruling the roost, several prominent orthodox doctors came together to forma national organization to represent the needs of orthodoxy, the American Medical Association (AMA).  Founded in 1847 largely by Nathan Davis, the AMA had several goals: To promote licensing requirements, to standardize education, and to provide a collective where all orthodox doctors could gather.  Although formed as a democratic union of orthodox doctors, the organization from the start sought to stamp a unifying dogma upon its members and the nation, one that included the medical racial script.  In fact, the script helped to congeal doctors under a single rubric of medical science, one shared by doctors North and South.  Weak from the start, the AMA hobbled along for many decades before emerging as the predominant Progressive force in American healthcare, one destined to change the system into the one we know today.

Transcript

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Hi everyone, and now it's time to talk about the AMA or the American Medical Association. Um, it's it's kind of strange because the AMA is a feckless organization today. As a doctor, I know that uh very few doctors belong to it. It no longer has the power it used to, but one point it was the most powerful force in medicine, and that lasted probably up to about um the year 2000 or so. And in the 50s and 60s, 1950s and 60s, it was so powerful that a doctor could not survive without being a member and without being someone who didn't dispute the policy of the AMA. They were able to change insurance policies, they fought against all sorts of things in medicine, and they controlled every tentacle of the medical establishment. That all started in about 1915, which is when this course ends, but this AMA itself started in uh 1847. Took quite a while for this little group to become that important, and that's a lot of the story of what we're going to be talking about now, because they did shape healthcare today, and the healthcare we have now is a reflection of their agenda that started way back in 47. Um, a lot of people have written about the AMA, but no one's really written a good critical biography of it. It's funny, the two biggest biographies of it are written by AMA insiders, and there have been a lot of articles also written by AMA insiders. Um, one of them, uh Lester King, who is um a prominent member of the AMA, uh says that the formation of the AMA was like the formation of a guild, that the goal was specifically to represent the interest of its members. And it's really important to know this from the beginning, there was no um there was no purpose of the AMA to help patient care, to be advocates for patients. This was an organization that was an advocate for doctors, and it was felt as though if you get the right kind of doctors in America, then patients would subsequently do better. Um King writes, quote, a medical society is not a philanthropic or altruistic organization. And that is something that it's it goes without saying uh these days. Um the uh the challenges to the profession were discussed previously, that there was a huge influx of alternative providers that we'll talk about more later. There was a lack of oversight regarding licensing and education. Um, people who were uh Orthodox doctors were not considered quality. They were killing a lot of people, their skills were not good. There was a huge discrepancy between those who had really good training and those who went to basically medical diploma mills, uh, which were propagating across the new country very quickly. Um there was um also extremely low pay for doctors back then. They were among the lowest paid professionals, and and people would do almost anything else than be doctors. There were there were some uh surveys back in the late 1800s, especially that showed that doctors were about 10th place on the list of what people would do uh if they had a choice, below many other things. Uh, Paul Starr, whose amazing book, The Social Transformation of American Medicine, that was written in the 80s, I actually used it for my thesis when I was in college back in the 80s. Uh, he writes, quote, doctors and other professionals have a distinct basis of legitimacy that lends strength to their authority. They claim authority not as individuals, but as members of a community that has objectively validated their competence. And this became the driving force for the creation of the AMA as a mechanism of liberal orthodoxy consolidation. If we could get together, if we could all speak in the same language, if we could expunge the medical community from those people we call quacks, then our status will improve, our salaries will improve, and in the end, they believed what we do for patients will improve. Nathan Davis was probably the man who was most responsible for founding the organization, but it was also founded by a lot of other young Orthodox doctors who received their training, not in Europe but in the United States, and who uh were hurt very badly by this laissez-faire attitude of America that allowed anyone to practice medicine, any medical school to open, and to have no licensing. So that became really the goal of the AMA. Um, let's set up licensing laws, let's control medical education, and let's control the narrative. Let's make Orthodox medicine as we see it the only law in the land. And Nathan David said, quote, it's been said by someone that associated action constitutes the mainspring, the controlling mode of power of modern society. And the crux of his very brief statement is clear. Orthodox doctors needed power if they were going to triumph in this medical landscape that seemed to be favoring quacks. Never in his writings, interestingly, does Davis or any of the other founders question the validity of Orthodox medicine? They don't bring up the fact that so many people were dying, that there were there was not really a good consensus as to what constituted good treatment. To him and the other founders, it was extremely implicit that orthodox medicine was the only form of medicine, and that a poorly regulated medical environment will allow substandard education and the proliferation of quack healers, which would destroy the very foundation of American healthcare. The um uh younger doctors who helped found this uh organization were often from the South. In fact, the the South uh provided uh at least half of the presidents during the early age years, and many of the founders. And many of these people were people who were part of the American school too, people who had done a lot of work on African American bodies who accepted the um medical racial script. And in fact, the although not a single word about race is ever uttered in the AMA founding documents or in pretty much any AMA documents uh up until recently, uh with the exception of one event that we will talk about in 1870, uh that this was a group founded by the people who were brought up with the medical racial script. And so it's no surprise that there were not any African Americans in there. Not that there were any, there was one African-American doctor uh in the country in 1847, as we'll discuss later, but even later, that African Americans were not asked to join, nor were women until later. That women were asked to join earlier than African Americans, but uh not for quite a while. There are there are a few points of the AMA founding that are really important. Um, first, from the start, uh Davis assured that the organization be federalized, that state medical societies would be the army. So each state would have a medical society. Already, a lot of medical societies have sprouted up across the states. And some states have many, many medical societies, and there were gonna be the pro-M AMA medical societies and the anti-AMA medical societies. They, Davidson, the founders believed that the medical societies were gonna be the on-the-ground groups that set the agenda. Um, the reliance on states to set the agenda and the need for that agenda to be universally accepted required there to be uh a cohesion. And part in many ways, the medical racial script uh helped create that cohesion in America, as we will show. But also the ideas of Europe that we are gonna put the physical exam above uh much more um uh tried and true uh ideas that had been utilized for centuries, were discarded. This was going to be new medicine. Second, doctors and medical scizees must adhere to a code of ethics. And the code of ethics was drafted by several of the founders. It's funny, one of the most prominent founders who uh scripted this code of ethics was Paul Eve, who was a Southern doctor who um uh experimented on black bodies without their consent and often killing people in the process. But he was the guy coming up with a code of ethics. And anyone who didn't follow the code of ethics uh would be disqualified from memberships. Um anyone who worked with, conferred with, an alternative provider, a homeopath, or anyone else would be immediately kicked out of the AMA. Um and the AMA in its founding documents uh claims that these uh alternative providers, quote, swarm like locusts in every part of the country, who, like so many epidemics, have in successive ages excited the imagination with extravagant expectations of the cure of all diseases and the prolongation of life beyond its customary limits. Uh, one of the AMA historians, Marshbe Fishbein, who was actually an AMA uh prominent member in the uh early 1900s for about 20 or 30 years and was who ran the journal, uh states that, quote, from the very first, the American Medical Association has prosecuted its war on quackery. This became its modus operandi. Third is a national organization representing all the states. Uh, the AMA members needed to adhere to a unified script that would be delineated as the AMA grew. Each meeting, each annual meeting would have more and more tenants to this orthodox dogma that could not be broken. Um fourth, the AMA must spearhead reform of medical education and control medical education. This became a prominent part of their agenda. They would tell what they would they would create the curricula for medical schools. Fifth, all states must adhere to strict licensing. So only doctors licensed by states could practice, and only doctors who were AMA members and went to AMA-sanctioned medical schools could get licensed. This is what they wanted. This certainly was not occurring in the America of 1847 or even much past that. And uh finally, uh the AMA was going to be a gathering place for Orthodox doctors to share research, collaborate medically, and organize as a fraternal unit. So they will not only push for reform, but also be a gathering place where they could share information. And this is this is something that became important to even the state medical societies, that they were places where people could go and gather. So the first meeting uh in 1847 uh attracted uh whopping 266 doctors. They elected as president Dr. Nathaniel Chapman of Philadelphia. Um, and Paul Eve was one of the early vice presidents and became a president uh in the 10th year. I've read through all the founding documents and uh and and it's interesting. If you go on um uh the AMA website, you could actually get the transcripts from every meeting from 1847 up to the present, and they are fascinating reading. Most of the transcript is filled with scientific papers. Interestingly, at least early on for the first 50 years or so, most of those papers um had something to do with racial medicine because that's what the research was in America. But um that they didn't talk about that, like I said, that this was let's talk about science. The science was the science that was created by AMA members uh and by other people who were felt to be prominent in the country, and uh we were going to spread that information, and then each specialty of medicine was going to have a forum where they were going to talk about what they wanted, then then came the uh part of the AMA that was much more policy making, and there was an education division, there was the ethics division, uh various divisions that talked about ways licensing that they were going to make their goals heard. 266 members, eh, not not much, not much going on uh early on. Um, so this was the early AMA, and um at least for its first several years, it really did not accomplish anything. It is interesting that in 1858, when Paul Ebe became president, he praised the AMA's first 10 years of success. And the next year in uh the AMA stated in his transcripts, quote, we have seen the AMA in its brief existence uh gating into its fold thousands of members, members from every state of the republic, and without processing real legislative power, exercise a most potent force for good. But the transactions from these meetings during this time attest to the organization's frustration at being unable to convince its ill-defined audience to press for licensing or educational reform, even as it's praised its own accomplishments, nor is there evidence that there are more than a few hundred members at any time in the AMA. Whether there were members and who went to the organizations, um, certainly just a handful of people went to the organizations. And in the spirit of America at this time, the organization was incredibly open. If you showed up to the meeting, you were able to speak your mind. You were part of a committee. There was no hierarchy in this committee. The AMA was a free-for-all of orthodox doctors, and in some ways, this led to chaos during most of the meetings. There was a lot of fighting about who spoke with this quack or that quack, and that that's generally what they yelled and screamed about because that was the biggest reason to break the code of ethics. Going back to Foucault, who we mentioned before, especially with his amazing book, uh The Birth of the Clinic, that I recommend to everyone. Um, Foucault obviously didn't talk about the AMA. Even he wrote in the 1960s, but he was writing mostly about the origination of modern medicine in France at the time. Um, the AMA, again, for the all the 1800s, um, was a blip, uh, barely discussed, barely affecting uh doctors' practice or the way medicine grew in the country, um, which we will talk about. Uh, but you know, Foucault writes that Orthodox doctors advocated, quote, a strict militant, dogmatic, dogmatic medicalization of society, unquote, and states that, quote, medicine would be practiced more in accordance with normality than with health. It formed its concepts and it prescribed its interventions in relation to a standard of functioning, an organic structure, and physiologic knowledge that sat at the very center of all medical reflection. So, in other words, with the new medicine that was being practiced, and this is something the AMA believed in, that there was a singular truth, and that the AMA would, in its corpus, define what that truth was, make sure licensing was based on that truth, make sure all doctors practice with that truth. It would be the arbitrator of what that truth was, and all medical schools would have a curriculum that uh supported that truth. That truth was still being defined by doctors at the time, but a lot of it had to do with research. The medical racial script was really central to it. The idea of the physical exam, especially with a stethoscope being more important than speaking with patients, the idea that the humoral theory was now fairly debunked, all that became part of the AMA corpus. Uh, there was very little discussion of therapeutics, whether bleeding people was dangerous, other than that of new drugs coming out. And it's very important to know that at this juncture, and and as was prescribed in the code of ethics, that patent medicine salesmen were considered quacks. They were in the list of quacks. So while herbal medicine was not directly assailed by the founders of the AMA, the patent medicines, which were largely based on a lot of the old herbal uh ideas, uh were uh distrusted and debunked. It was felt that that was not the way to treat people, that only medicines directly authorized and sanctioned by the AMA could be used by doctors. This was not the case in America. There is the AMA, Nathan Davis and the others who formed it, um, and then there was American medicine. And American medicine was not what the AMA said. American medicine was the Wild West. That people were prescribing patent medicines left and right because that's what patients wanted. It's funny that Osler, William Osler, who we'll talk about a lot, who was pretty much uh the antithesis of the AMA and who did forge a path that we didn't follow, uh which we could have. The AMA path took precedence. But um Osler said one of the duties of a physician is to stop patients from their obsession with taking pills. The AMA in some ways felt the same way, other than pills that the AMA supported. Um, and as we'll see later, this became crucial to the growth of the AMA when they changed their tune about this. Uh so at this time in the eight mid-1800s, from about 1847 until the dawn of the Civil War, uh, there was no licensing. There was no federal or state licensing. There was no uh particular agenda in medical schools. The medical racial script was fairly universal because the ideas of research that were performed in America and the need for cadavers and um a need for a unifying ideology, which was the idea of um blackness being a disease, um, whiteness being uh something that we should be lauding, um, the idea of disease being uh discoverable through the exam, the idea of using the same old techniques that were used for hundreds of years with the addition of some new herbs and medicines. Uh that was that's what was going on in the country. There were lots of doctors, they were um getting paid very little. And honestly, at this point, Orthodox doctors were in trouble. The AMA did not change that calculus. And we'll see in a future talk uh that alternative doctors were uh much more trusted, they actually got paid more, they they had a more rigorous and unified education than uh people who were orthodox doctors at this time. Orthodoxy is what we know today, and when we talk about the physical exam and the and the nature of what the AMA was trying to propose, that's the norm today. But back then was not the case. So some of the readings this week will help uh illuminate this. I did put in some things from the trans transactions of the AMA, which I always find really fun to read. They're short and they they could be funny just from what they talk about. I mean, sometimes they're spending more time talking about where their next dance is gonna be than anything else. They they really were a little club trying to get together and they were fighting against the world, and they thought that their fight was the most crucial fight that there was, and and they never relented. And to some extent, that's why we have the system we have today. So um enjoy the readings and uh uh we will um now talk about some uh racial and alternative uh medical ideas that popped up uh especially around the time of the Civil War.