Lecture Ten: The Cogs of AMA Reform

The AMA grew up in a libertarian America, but chose to change its nature during a top-down Progressive America, where experts and scientifically based rules were determined to be crucial to any viable reforms.  Working with corporate foundations, Progressive reformers, and German-inspired Progressive academic doctors, the AMA shifted course and transformed into a top-down organization that sought to control all aspects of American medicine, including education.  It changed its structure to rely on a very narrow board of "experts," it adapted a German ideology of care, it worked with corporations and drug companies to increase its base of money and power, and it started to survey medical schools and determine which ones were capable of surviving in a new Progressive age.  All of this foreshadowed the Flexner Report, which would vault the AMA into total domination over the medical landscape, normalize German medical thinking, and create a formulaic dogmatic medical script that would be templated upon all medical schools and all licensing requirements.

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So we'll try one talk to bring up some of the salient points of how the AMA and Orthodox Medic was able to gain the foothold of the American medical landscape between 1900 and 1910, uh, culminating in the 1911 Flexner report, which changed everything. And we will spend the whole lecture on that. Paul Starr, the amazing historian of medicine at the time, uh states that, quote, the federal structure of the AMA adopted in 1901 was in fact copied from other national organizations. And he makes a good point that the AMA used the progressive idea of top-down reform as a way to restructure itself. And at that point, as he and others note, many, many progressives uh who studied in Germany and who were part of the progressive movement, such as William Welch, um believed that the AMA could not be a democratic organization anymore. It had to uh not only change the medical curriculum to be more German, uh, and Welch had an idea of exactly how that would be. Something he had been trying to adopt at Hopkins uh and somewhat succeeded and was able to uh uh complete his reformation in 1903 when his nemesis, William Osler, retired, and we'll get into that more. But Hopkins became his model, especially what he created after 1903 for what the AMA was now going to promote as German medical science, and all medical schools would share that singular template. But of course, to do that, um they had to fix themselves, they had to make themselves into a progressive organization, not only in thought, but also in apparatus. They had to be top-down. No more fighting. Oh my god, reading the AMA transactions from these years. It's all about fighting. Um, that's all they did. That was gonna end. And it's funny because after 1900, the transactions uh became uh extracted from the major record, and you could find them in the journal, but they were mostly transactions of of these meetings that meant nothing. The AMA meetings continued, people argued, but now this was not part of what the AMA did to uh to uh instigate reform. That was done in a small group in Chicago. So a couple things. Um let's let's talk about how it reorganized and and what its priorities were. Um it really wanted to remove any doctors that it did not believe were going to fit the Orthodox model and who are going to fight with them. And we said that they changed their um their their uh uh code of ethics to allow homeopaths to join, but there was a caveat there. Homeopaths still had to attend an Orthodox medical school, they still had to believe in some precepts of Orthodox medicine, and many of the reformers um were former or even somewhat current homeopaths, like we talked about during our uh discussion of pharmaceuticals, but they were part of the orthodox movement too. So it wasn't so much as the AMA's change was there to enable homeopathy to continue, but rather the goal was to incorporate these white doctors into the AMA orbit as orthodox doctors who were going to go with the plan. White male doctor unity was the goal, and there had to be a singular message. No more, no more of this fighting. One of the methods the AMA used to do this was to use the local medical societies as the army on the ground. And we already talked about how the AMA had strong relationships with local medical societies. At a certain point, groups like the Massachusetts Medical Society and the New York Medical Society uh did not like what the AMA was doing and broke away from them, threatened to create a new national organization. This was not going to be allowed to happen anymore. From now on, every society that was going to be an AMA affiliate was going to listen to the AMA's rules and was not going to fight with them. And the AMA picked one society in each state that was going to play that role. Now, why would a doctor join one society versus another society? And in fact, in 1900, um of the nearly 100,000 or more than 100,000 Orthodox doctors, 8,000 uh had AMA membership, 33% belonged to local societies, most of which were not AMA affiliates, and 77%, 77,000 belonged to no organization at all. Uh, not a local society, not the AMA, nothing. And the reason was they had nothing to gain from being in these societies. And so the AMA realized it had to change the appeal of local societies. It could do nothing in its current democratic formula formulation. So it changed its constitution. Some of its most prominent leaders, including Welch, led this. And what they did was create a group within the AMA that exists today called the House of Delegates. The House of Delegates was a fixed cadre of leaders set at 150 people. If someone died or left, then the remaining House of Delegate members would vote in a replacement. And it's important to know that the leaders of the AMA were the original 150 and they kept the group small and tight. And many of the things they talked about, I found some of their stuff in AMA archives at AMA headquarters, but it's not publicly presented in the journal or in their transactions. They had their own agenda and they kept it pretty secret, which was the top-down nature of progressivism at that time. One of the most prominent members was a guy we'll hear from again, NP Calwell, and he has a lot of things written that you can only find in AMA headquarters. He was head of the American, the of the AMA's Committee on Education, which was crucial to its reform efforts. And he wrote that unless, quote, state boards adapt effective state safeguards, they are apt to become dumping grounds for illiterate, poorly trained output of low-grade doctors. So he he, among others, believed they had to reshape these local societies into potent conduits of orthodoxy and make these societies the only places that doctors can go if they want to be part of mainstream medicine and be licensed. It was crucial to tie licensing reform, which progressives really were pushing. Progressives are all about licensing and having uh small cadres of people leading and having them licensed and taking exams and tests and passing exams. A lot of what any pre-med knows today or any medical student is you got to take one uh uh test after another, and they're all multiple choice tests, and because multiple choice became a standard of progressive and eugenic uh uh evaluation, because there was only one right answer. There's no nuance. If you have an open-ended question and open-ended answers, there's too much nuance. But no, there was one right answer. Of those four questions, one of them is right and all the others are wrong. This became a norm, which again, we we kind of accept today, but it was not a norm before 1900. In fact, there were no tests any doctor had to take before 1900. But the first step of this was that doctors had to join local societies. Well, one of the in addition to the other things local societies did, which was to help promote licensing laws and to push the AMA agenda and also to be a place where doctors could gather and meet, um, they also intelligently leaped into the malpractice uh arena. And it it was during the late liberal era um when lawyers became so prominent and people would get sued left and right that there was literally a tsunami of malpractice suits against doctors, and they had to turn to a growing insurance industry. Again, insurance was part of the the progressive agenda, the insurance industry, doctors had to pay for this insurance, we still do, um, against potential of malpractice because there were just so many. You you could do almost anything. Of course, orthodox doctors now were at that point were killing people left and right. So if a bad outcome came, you could, you know, a person go to a lawyer and sue them and get a lot of money. So the the leaders of the AMA um worked with reformers, progressive reformers, and state legislatures to make the AMA local headquarters a place where doctors can be protected from the sting of malpractice. And um as uh as Paul Starr writes, uh quote, it became almost impossible for patients to get testimony against a physician who is a member of an AMA affiliated local society. The local medical fraternity became the arbiter of a doctor's position and fortune, and he could no longer choose to ignore it. So for people for doctors to get protected from this malpractice, for them to be able to withstand trials and lawyers, joining state societies became crucial. In addition, the progressive reformers pushed that um state boards of health and other uh state and federal agencies that conducted health care, including the public health administration, required uh membership uh in a local medical society affiliated with the AMA. And ultimately AMA membership itself, because a lot of um these local societies required its members to join the AMA at the time. So AMA membership started to boom because now we are we were getting um doctors who felt that they could gain something from it. That had never happened before. In fact, the AMA in 1905 created a national physician directory that listed doctors based on their membership to local societies and to the AMA and to which school they uh graduated from. Because at this point, the AMA, as we'll talk about, started ranking schools. And if you were at an approved school, that became important and they created this designation. Interestingly, they did include a few African-American doctors because some of them were graduating from traditional white medical schools. They they estimate from everything I read, about 10 a year went to traditional white medical schools. But they received an N after their name as Negro, and that became part of the directory until 1936, when uh, for reasons unknown, they rejected it, possibly because they had already won and they didn't need to segregate doctors anymore. By 1910, uh, after this thrust was really pushed hard, and again, the AMA had money to do this, the money to lobby, um, money to uh give to the local societies, to help with malpractice, to help doctors with education, um, to help with the testing process that became more and more prominent. It had the money. And by 1910, the AMA reorganized into a federation of mostly all white medical societies controlled by a central bureaucracy of 150 people whose own elections were self-made. Not the big group, but the 150 elected each other. They tied physician solvency and ultimately physician salary and uh prevention and malpractice to membership in the societies, uh, and ultimately started to convince state licensing boards, again, through a lot of progressive muck-raking journalism and uh a lot of progressive um people higher in the governments to tie licensing to membership into the society, into the AMA, or at very least into a local society. All of a sudden, we see after 1905, states passing licensing laws about everything, not just medicine, but their medical licensing laws were explicit that doctors had to take a test, a multiple choice test authorized by the AMA, based on German ideas of what makes for good medicine. Um they had to be a member of the at least local medical society, if not the AMA itself, and they soon had to graduate from AMA-approved medical schools. The idea of reforming medical education had been on the plate since the AMA's founding. In fact, one could argue that Davis um created the AMA to reform medical education, and throughout its years, especially under Davis's tutelage, he talked about that more than anything else. Uh, and was unable to do anything. The the proliferation of medical schools, homeopathic, African-American, women's schools, proprietary medical schools, which Davis hated more than anything. These were medical schools that essentially took money from wealthy people and gave them a degree, whether or not they went to school or not. Um these were becoming more and more common. The AMA could do nothing about it. And this became, again, crucial for the AMA to make the leap into a progressive top-down organization. They had to control medical education. And to do so, they again leaped on the progressive train. Many of the people in the AMA believed that we needed to follow the German model of education. This became also crucial because who else wanted this model to be part of the educational system? The corporate foundations. The corporate foundations, again, especially um Carnegie and Rockefeller, but also Rosenwald, there were others, um wanted a bonanza of research. They wanted to be in on it. And they believed that that had to happen in the medical schools. The medical schools could become research facilities, create drugs and other products that could be sold, and they were willing to invest heavily in that. You have to understand, too, for a school to develop a research facility that was considered adequate, Germany had very few medical schools. So the state, the country, put a lot of money into them to create these pharmaceutical behumoths that came out of medical schools. To do this required a lot of money. You couldn't just transform a school, which sometimes was just a little place in a house where you did went to some lectures and maybe, maybe, but not always, you'd go to a hospital to get some clinical training, um, training with patients. That wasn't always the case. It certainly was in the big places like Hopkins, Harvard, Yale. Um, but uh yeah, to get labs in these places to expand facilities, and also to get what was also considered crucial at the time, uh, and which came from Germany, was full-time faculty. We did not want just quack doctors teaching medical students. We wanted people hired by the university who were laboratory doctors teaching medical students. And the essential German breakdown of medical schools, which was completely different than what was occurring in America at the time, was that two years would be devoted strictly to science. You would sit there and learn, sit in a classroom and learn about physics, chemistry, biology, anatomy, physiology, pathology. You would learn this stuff. And then you would go the next year or two, depending on the school, um, and work in a hospital and kind of put what you learned to use. Uh at this time, there was no further training needed. Uh, we'll see that um it was it was actually William Hosler who created what was called the residency, where you would then get basically apprenticed by other doctors and then go out and become a doctor and get licensed. So, this is what they wanted to create this exact template of a medical education system, and they wanted it to be the same for every single school in America. For you to be at an AMA-approved school required you to be a school exactly like this, a school with full-time faculty, with labs, with this basic science curriculum followed by some clinical training. This is what progressives wanted. This is what the AMA believed it could latch its uh its progressive um reforms onto. In 1903, um the AMA president uh Billings said that the dual goals of the educational reform would be to establish full-time research scientists as medical school teachers and to eliminate all for-profit and substandard schools that seek to fund themselves from tuition. He and Davis had before him believed that tuition would make these schools bad because then the schools would be seeking money from students. And he believed that money should be coming from above, from corporations and other reasons. He he wrote, quote, medical is billings, medical school, which is conducted for commercial reasons, must go because they cannot command the money to build, equip, and maintain the laboratories and hospitals which proper and adequate medical education demands. And of course, the corporate foundations were all about this and willing to fund these transformations. But so obviously, not all schools could do this. So it was a big task. The AMA wanted to restrict the number of doctors. Why? Because fewer doctors means higher pay, higher prestige. They wanted doctors to have to go to a school that it supported. And how did it do it? So it was actually Calwell and his Committee of Medical Education that between 1905 and 1908 inspected and ranked all 160 American medical schools. It declared 82 to be potentially salvageable. This included only two of the African-American schools, Mahirony and Howard, none of the schools that train women, and none of the homeopathic schools. Um of these 82, um, a smaller number it felt could be transformed more quickly. Calwell and others again worked with progressive muck-raking journalists. Um, he wrote, quote, 3,000 incompetents are being dumped into the unsuspecting public each year, i.e., doctors who came from these schools that were ranked low. Most of which, again, other than the schools that trained specific niche groups of people that were not white orthodox doctors, the other schools were proprietary primarily. Schools that were small and got all their money from students and were often extremely corrupt. Um, so the progressives and they agreed on this. And both were willing to push state licensing laws to start to look at this. This became now a criteria for licensing which school you went to. It was not universal across the country, some states more than others, but it was becoming much more common. But again, it was very expensive to do, and if you're only getting money from um tuition, it's gonna be very difficult to do. Uh the the um the head of the CEO, Calwell wrote, quote, Medical research is the very soul of medical education. Without it, the medical school is a mere machine teaching the discouraging facts regarding morbid processes, sickness, and death without the inspiration of encouragement and hopefulness that comes from delving after new truths and from discovery of new methods of alleviating disease and pain. Unquote. Again, progressive ideas. We're going to use science. We're gonna we're not just gonna just talk about diseases and talk to people. We're we're gonna dive into the laboratory and actually be part of the process of science, of reformulating um the medicine. And guess what? As progressives started to push the AMA agenda, um, as the AMA became had more money, as it had um uh journalists who are are are were basically trumpeting its ideas, um, as it became more corporatized and top down, it was able to start. Effectuating some of these changes. And it was in 10 years an incredibly dramatic transformation of this organization. So one of the biggest problems that occurred was that there was still no national standards. This was all being done mostly on the state level. And that's really where the AMA wanted to go. But before we turn to the Flexner report, which is what created the national standard with which we live today, let's talk about two players in this whole drama. Because if you just read the AMA records, if you read progressive uh discussions of healthcare reform, you miss some of the nuance, some of the fighting that was occurring. The AMA no longer had overt fighting within its doors. A little argument that occurred at meetings was largely silenced. The AMA became a unified organization led by a cadre of people and by these local societies, all that spoke in one voice. But that voice was not uniform across Orthodox medicine. We already know that there were many homeopaths that were not jumping on this train, even if the AMA invited homeopaths in. And obviously the African-American medical community was not invited in, and that was fairly large at this point. But there were several prominent Orthodox doctors who simply did not want to go in the German progressive direction and believed in an entirely different avenue of medical education and medical reform to get rid of quackery, but to do it in a different way. The leader of that movement was William Osler, who's probably the most famous American doctor. You could walk around Hopkins now and see Osler Hall and statues of Osler. He was one of the founders. But it's kind of ironic because Hopkins rejected everything that Osler did and adapted everything that its other primary founder, William Welch, did. And to see the dichotomy between these two prominent doctors really shows what could have occurred and what did occur. And that's important to know, especially among healthcare reformers today, that there was another avenue, another road that we could have gone down in orthodoxy. And we chose not to. Welch, who was a pathologist who studied tissue in the lab, never saw a patient in his life, felt differently, felt everything was lab-based. And the fight that these two had, which by the way ended in 1903 when Osler retired and enabled Welch to push Hopkins out of the Oslo orbit and also to push uh American medicine out of the Oslo orbit, that fight is important just so we could understand that at least at that juncture there were other possibilities. And so we're gonna let's talk about these two guys.