When were doctors first licensed in California?

Toland Hall, Medical Department of UC San Francisco 1874

In the 1870s, physicians across the United States pushed state legislatures to implement medical licensing. At this time, all doctors in the the United States were unlicensed.[1] Additionally, the United States was composed of a crazy patchwork of physicians from different sects competing with each other. The three largest sects were regulars (traditional M.D.s), homeopaths, and eclectics (a mixture of Thomsonians and disaffected regulars). Eclectics, homeopaths and other non-M.D. physicians were often referred to as irregulars. These sects represented completely different approaches to medicine.

By the 1870s, regular physicians were committed to regulating medicine. They believed that state licensing was an necessary first step to control the medical marketplace. Initially, regular physicians sought to use licensing to prevent homeopaths and eclectics from practicing, but in states such as California, they quickly realized that would need to work together if they wanted the state legislature to create medical licensing.

Stumping for Medical Licensing

In 1870, the Legislature created a California State Board of Heath with the goal of looking “after the vital interest and physical condition of the people.” The Board was composed of seven physicians from Sacramento and five doctors from other parts of the state. The legislation did not bar Irregulars from serving on the board nor did it require it. Still, all of the members of the inaugural board were Regulars. One of the chief responsibilities of the Board was to propose bills to the legislature that could improve public health.[2]

In 1874, Thomas Logan, one of the most prominent members of the CSMS and the permanent secretary of the California State Board of Health, began an earnest effort to enact medical licensing in California. Logan made a strong case at the 1874 California Medical Society meeting that it was crucial for physicians to began to assert control “over admission to its ranks.” He also argued that the disputes among the sects not only appeared to be “useless and unseemly” to the public, but they were counterproductive because these disputes “prevented or defeated all efforts to obtain legislation that would have … protected the people against medical frauds and ignorance.” This conflict had weakened an already diminished profession. “Physicians of moral worth and personal dignity” were reduced to opposing any measure that would allow them to be categorized as a physician along with the numerous “shams and frauds” littering their profession. Logan argued that as long “as the demand” for licensing “is made irrespective of all so-called schools of medicine” the Legislature would be unable to “refuse.” Logan called on the CSMS to support a regulatory bill that would create an independent board of medical examiners that would license all applicants and criminalize the practice of medicine without a license.[3]

Logan was not the only person calling for the creation of medical licensing in California. The Los Angeles Herald advocated on behalf of medical licensing in July 31, 1874. The editorial asked why ship pilots were required to secure licenses while physicians “were permitted to practice medicine without written evidence of their right to kill or cure the human family[.]” The editors argued that unlike lawyers, “the ignorance and efficiency of the quack doctor” were not apparent until “one or more lives have been sacrificed.” The Herald demanded that the state of California needed to require physicians to get a license in order to “suspend operations” by “these murderers.”[4]

Proposing a Medical Licensing Law

In 1875, Logan presented a bill to the CSMS that could be best described as a confusing jumble. Instead of creating a single unified body, Logan’s bill dispersed the authority to grant licenses to four different groups which, in turn, could license physicians in three different ways. First, physicians could present a “diploma” from a “bona fide” and “regularly chartered medical school” directly to the county clerk. Second, they could get a license from “a State Medical Society, or a State Board of Medical Examiners.” Finally, physicians also could secure a “certificate of qualification” from the State Board of Health, any of the state’s medical societies, or a state board of medical examiners. Additionally, the county clerk offices were required to determine whether a medical school was a “bona fide” institution.[5] The proposed bill was originally presented by the California State Board of Health in its biennial report. The bill was modeled on a Nevada registration law that was adopted a year earlier. The bill did not license physicians who lacked a medical degree, and it would have been opposed by a number of state’s Regular physicians for that reason.[6]

After the bill was read, one member of the California Medical Society expressed concern that it was too long and proposed adopting the Nevada registration law that had been approved there. In lieu of approving the bill, it was submitted to a committee of three members who could reevaluate the proposal and report to the Society at a later date.[7] The CSMS failed to reach any definitive decision regarding the proposal and essentially punted it to a later date.[8]

Logan’s bill was not the only one presented that year. The San Francisco Medical Society also proposed a similar law, but that one authorized the creation of a “Board of Medical Examiners.” This board would be composed of seven practicing physicians who would be responsible for evaluating diplomas and conducting a “critical examination” of all medical licensing applicants. If an applicant presented a valid diploma and passed the licensing exam, the board would confirm the identity of each applicant to ensure that they were not practicing under an assumed name. The Sacramento Daily Union questioned whether it was necessary to every physician who wanted to practice in the state. The Union argued that it would be inappropriate for a select group of California physicians to question the judgments of American medical schools and “the Medical Colleges of Europe.” The editors of the Union believed that California lacked physicians who possessed either the skill or credibility to question these august institutions. They argued that California would be better served if they relied on these schools to furnish “evidence of competency” for the prospective physicians.[9]

Passing Medical Licensing

San Francisco 1878

Finally, in March 1876, after a year of debate in the legislature, the California Assembly and Senate passed an act to “Regulate the Practice of Medicine in the State of California.”[10] It permitted graduates of medical schools to practice without being tested by an examining board, but it differed somewhat from other licensing laws passed the 1870s, because it authorized “each State Medical Society, incorporated and in active existence” when the bill was passed to appoint seven people to separate boards of examiners. Potentially, each medical society in the state, including Homeopaths and Eclectics, could create their own boards, but there was a complication. The California State Medical Society of Homeopathic Practitioners (CSMSHP) strongly supported the passage of this law and adamantly opposed a single unified board. The multiple-board bill was approved because CSMSHP brought “influences to bear” and persuaded the Legislature to side with the more liberal law.[11] The statute mandated that in order for a medical society to supervise licensing its medical sect, the society had to require that its members were “to possess diplomas, or a license from some legally chartered institution” at the time when the law was passed. The bill also sought limit the influence of nostrum peddlers by requiring any “itinerant vendors of any drug, nostrum, ointment or appliance” to pay one hundred dollars a month.[12]

Before the bill was passed, the legislature engaged in a lively debate about the bill and numerous amendments were proposed in an attempt to radically alter it before its passage. The biggest debate centered around which existing physicians would be automatically licensed under the law. The bill originally proposed that physicians who had practiced in the state for twenty years could apply for a license if they could get two recommendations from other physicians who were in good standing. There were several attempts to reduce the number of years those physicians practiced in the state. Initially, the author of the bill rejected a proposal to reduce the number from twenty to fourteen years, but a later amendment changed the twenty-year requirement to only five years. This undoubtedly helped the law pass the legislature, because far more physicians from the three sects would have supported this law. The legislature would have struggled to pass this law without adopting this significant change.[13]

The Sacramento Daily Union generally supported the passage of the state licensing law, but its editors expressed a few misgivings. The Union was concerned that the provision requiring itinerant physicians to pay one-hundred dollars a month was potentially unconstitutional, but the Union still supported the measure because it attacked that “class of swindlers.” Still, the editors were concerned that this provision explicitly discriminated against a “class of strangers” and could be undone by the courts. The editors for the Union hoped this would be avoided because the law potentially would alleviate the antagonism among the three major sects.[14] The medical sects also were pleased with the law and quickly sought to enact its provisions.

Immediately after the law was passed, the CSMSHP set up its own examining board of seven members in April. After forming its board, the CSMSHP faced many unforeseen circumstances. The Secretary of the Homeopathic Board of Examiners reported that prospective physicians began offering large bribes to board members from each of the boards. The Homeopathic secretary weakly proclaimed that fewer bribes were made to the Homeopathic board than “either of the other Boards.” Still, physicians offered a variety of different bribes to members of the newly established Homeopathic board including “notes of $50 to cash of $200 to secure certificates,” potential business partnerships, “compensating favors,” and an offer to create “an endowment of untold thousands” for a medical college. The Secretary then assured the readership of the California Medical Times that even though he was “startled” and “nearly captured” by the offer to create a medical school endowment, these offers were “courteously but firmly informed that money, beyond the medical fee, would not buy certificates.” At the end of the day, the Homeopathic board issued eighty-nine licenses (sixty-five via diploma and twenty-four by examination.)[15]

As the medical societies were establishing their boards, the law came under attack from multiple parties (both Regular and Irregular). In 1877, the President of the CSMS, W. Fitch Cheney, M.D., ranted that the bill contained “many absurd provisions.” The statute forced the Regular Examining Board to lose money because it did not authorize the board to charge enough to cover the printing costs of the exam. In addition to losing money, the Examining Boards were required to hire more people to handle additional clerical work. Cheney sought to amend the bill to allow the society to charge more to administer the exams. Additionally, “three or four” members of the CSMS did not pass the medical examination, which cast the Society in a negative light. One of the society’s members was outraged that the CSMS had done such a poor job policing its own members that quacks apparently had infiltrated its ranks.[16]

Efforts to Amend the Licensing Law

Regular physicians in California did not have to pair the state’s licensing law with a public health measure. But they were significantly aided because the California Board of Health had been created the year before the licensing law was passed. Even though physicians did not piggy-back the state’s licensing on the creation of the board of health, members of the Board of Health in California strongly advocated on behalf of licensing as an essential component of public health. The board members’ support for licensing was unsurprising because all of the members of the board were Regular physicians. What was surprising was the state Regulars’ willingness to compromise with Irregulars. In many states, Regular physicians proposed laws that clearly sought to limit the influence of Irregulars, but in California the leaders of CSMS fairly early on were committed to compromising with Irregulars. The leadership of CSMS and the Board of Health in California never sought to eliminate Irregulars. The Regulars’ willingness to compromise encouraged the state’s Irregulars to quickly support the law and overcame any objections in the legislature.

One of the most consistent problems faced by licensing laws was that as soon as they were passed, special interest groups immediately sought to amend them in the next legislative session. Sometimes these amendments were proposed by Regular or Irregular medical societies, but often they were proposed to benefit a class of medical specialists who were disadvantaged by the existing law. There were a wide range of amendments proposed in states around the country to help itinerant physicians, unrecognized specialities, or some other group. California was no different.

Even though the law was passed with overwhelming support from the state’s Regulars and Irregulars, Ira Oatman, Chairman of the Committee on Medical Legislation for the California State Medical Society, fought tooth and nail “to defeat” subsequent legislation that upset the original compromise. Oatman often worked with several other state medical societies to defeat any and all proposals to amend the licensing law from the Regular society. In 1878, Oatman was faced with multiple bills that sought to upend the state’s law. There were so many proposed alterations and amendments to the licensing, and Oatman admitted that he struggled to keep abreast of all the proposals. Oatman’s struggle was not unique. After licensing laws were passed, legislators constantly sought to tinker with them.'

The California not only required examinations of all applicants, the new law explicitly, but it created separate Regular, Eclectic, and Homeopathic boards. Each of these boards was explicitly tied to the state board for each sect. Additionally, the medical societies retained the right to change the members without interference from the governor’s office. This effectively prevented any additional medical sects from creating their own medical examining boards, thereby establishing a medical cartel among the three dominate sects. Additionally, the law was altered to give the medical societies more money for examinations. Physicians who submitted false diplomas would be fined an additional fifteen dollars by the board. The examining boards also were required to refuse certificates to any applicant accused of unprofessional conduct. Finally, itinerant vendors were required to pay for one-hundred dollars licenses if they wanted to sell any “drugs, nostrum, ointment or appliance of any kind intended for the treatment of disease.” [17] Essentially, Oatman and the CSMS were successful in achieving almost everything they wanted from the 1878 amendments. Additionally, the 1878 bill enabled more rigorous enforcement of the licensing law.

One of the implications for the 1878 amendments was that non-graduates who had not presented themselves for an exam in 1876 had another opportunity in 1878. The Board of Examiners for the Medical Society of the State of California began advertising in newspapers providing notice to non-medical school graduates that they needed to take a medical examination to procure a license. One of the advertisements in the Sacramento Daily Union announced that all non-graduates had to go to San Francisco for the examinations. The examining board did not bother to schedule exams for Sacramento. The advertisement indicated that the board informed applicants that it would question physicians about why they had failed to take the earlier exam.[18]Allowing non-graduate physicians to apply for licenses even though they had failed to do so prior was a small compromise for California’s Regulars in order to achieve their primary goals.

Conclusion

Essentially, the three dominant medical sects got what they wanted. All three sects were officially recognized by the state and were given control over the medical marketplace. It also set a precedent that would extend throughout the country over the next 30 years. The three medical sects often worked together create licensing in order to freeze out physicians they believed were substandard. This cooperation would ultimately lead to a breakdown of these sects and their combination during the early 20th century.

References

  1. Portions of this article were originally part of the following work: Sandvick, Clinton. Licensing American Physicians: 1870-1907, Dissertation, University of Oregon, 2014
  2. Logan, Thomas, “Report of the Permanent Secretary”, First Biennial Report of the State Board of Health of California for the Years 1870-1871 (Sacramento, D.W. Gelwicks, State Printer, 1871), 16-17, http://books.google.com/ebooks.
  3. Transactions of the Medical Society of the State of California During the Year 1873 and 1874, (Sacramento, H.A. Weaver, Printer, 1874): 49-61, http://books.google.com/ebooks.
  4. “Show Your Diplomas,” Los Angeles Herald, Volume 2, Number 103, July 31, 1874, 2.
  5. “Report of the Committee on State Medicine and Public Hygiene in California,” Thomas Logan, Transactions of the Medical Society of the State of California During the Years 1874 and 1875, (Sacramento, H.S. Croker & Co., Printers an Stationers, 1875), 95-102, http://books.google.com/ebooks.
  6. “The Bill Against Quackery,” Sacramento Daily Union, Volume 1, Number 205, Dec. 4, 1875, 4.
  7. Transactions of the Medical Society of the State of California 1874 and 1875, 10-11.
  8. “Life and Professional Labors of Thomas Muldrup Logan, M.D. of California” Dr. J. M. Toner, Transactions of the Medical Society of the State of California During the Years of 1875-1876, (Sacramento): 136-137, http://books.google.com/ebooks.
  9. “Legislation Against Quackery,” Sacramento Daily Union, Volume 1, Number 232, Nov. 12, 1875: 2.
  10. “Annual Address by the President”, A.B. Nixon, M. D., Transactions of the Medical Society of the State of California During the Years of 1875-1876, (Sacramento, 1876): 25, http://books.google.com/ebooks.
  11. “Report of the Secretary of the State Board of Examiners” W. N. Griswold, M.D., The California Medical Times, Vol. 1, No. 2, October 1877: 26, http://books.google.com/ebooks.
  12. Transactions of the Medical Society of the State of California During the Years of 1875-1876, (Sacramento): 24-25; “Medical Bill Passed,” Sacramento Daily Union, Volume 2, Number 30, 27 March 1876, 1.
  13. “Consideration of Medical Bills,” Sacramento Daily Union, Volume 2, Number 22, March 17, 1876, 1.
  14. “The Medical Practice Act,” Sacramento Daily Union, Volume 2, Number 31, March 28, 1876, 2.
  15. “Report of the Secretary of the State Board of Examiners” W. N. Griswold, M.D., The California Medical Times, Vol. 1, No. 2, October 1877: 26-29.
  16. “Annual Address,” Transactions of the Medical Society of the State of California During the Years 1876 and 1877 (Sacramento, H. W. Weaver, Printer, 1877): 25–28, http://books.google.com/ebooks.
  17. Laws Regulating the Practice of Medicine in the State of California, Passed April Third, 1876, and April First 1878, (San Francisco, A. L. Bancroft and Company, 1878): 7–11, http://books.google.com/ebooks.
  18. “Important to Physicians,” Sacramento Daily Union, Volume 7, Number 67, May 8, 1878, 2.

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