The practice of medicine in the United States dates back to colonial times (early 1600s). At the beginning of the 17th century, medical practice in England was divided into three groups: the physicians, the surgeons, and the apothecaries.
Physicians were seen as elite and usually held a university degree. Surgeons were typically hospital-trained and they did apprenticeships. They often served the dual role of barber-surgeon. Apothecaries also learned their roles (prescribing, making, and selling medicines) through apprenticeships, sometimes in hospitals.
This distinction between medicine, surgery, and pharmacy did not survive in colonial America. When university-prepared MDs from England arrived in America, they were expected to also perform surgery and prepare medicines. The class distinctions and snobbishness of physicians over surgeons quickly changed.
The New Jersey Medical Society, chartered July 23, 1766, was the first organization of medical professionals in the colonies. It was developed to “form a program embracing all the matters of highest concern to the profession: regulation of practice; educational standards for apprentices; fee schedules; and a code of ethics.” Later this organization became the Medical Society of New Jersey. It remains the oldest medical society in the United States.
Professional societies began regulating medical practice by examining and licensing practitioners as early as 1760. By the early 1800s, the medical societies were in charge of establishing regulations, standards of practice, and certification of doctors.
A natural next step was for such societies to develop their own training programs for doctors. These society-affiliated programs were called “proprietary” medical colleges.
The first of these proprietary programs was the medical college of the Medical Society of the County of New York, founded March 12, 1807. Proprietary programs began to spring up everywhere. They attracted a large number of students because they eliminated two features of university-affiliated medical schools: a long general education and a long lecture term.
To address the many abuses in medical education, a national convention was held in May 1846. Proposals from that convention included the following:
- A standard code of ethics for the profession
- The adoption of uniform higher educational standards for MDs, including courses of premedical education
- The creation of a national medical association
On May 5, 1847, nearly 200 delegates representing 40 medical societies and 28 colleges from 22 states and the District of Columbia met. They resolved themselves into the first session of the American Medical Association (AMA). Nathaniel Chapman (1780-1853) was elected as the first president of the association. The AMA has grown to become an organization that has a great deal of influence over issues related to health care in the United States.
The AMA set educational standards for MDs, including the following:
- A liberal education in the arts and sciences
- A certificate of completion in an apprenticeship before entering the medical college
- An MD degree that covered 3 years of study, including two 6-month lecture sessions, 3 months devoted to dissection, and a minimum of one 6-month session of hospital attendance
In 1852, the standards were revised to add more requirements:
- Medical schools had to provide a 16-week course of instruction that included anatomy, medicine, surgery, midwifery, and chemistry
- Graduates had to be at least 21 years of age
- Students had to complete a minimum of 3 years of study, 2 years of which were under an acceptable practitioner
Between 1802 and 1876, 62 fairly stable medical schools were established. In 1810, there were 650 students enrolled and 100 graduates from medical schools in the United States. By 1900, these numbers had risen to 25,000 students and 5,200 graduates. Nearly all of these graduates were white males.
Daniel Hale Williams (1856-1931) was one of the first black MDs. After graduating from Northwestern University in 1883, Dr. Williams practiced in Chicago and was later a main force in establishing Provident Hospital, which still serves Chicago’s South Side.
Elizabeth Blackwell (1821-1920), after graduating from Geneva College of Medicine in upstate New York, became the first woman granted an MD degree in the United States.
The Johns Hopkins University School of Medicine opened in 1893. It is cited as being the first medical school in America of “genuine university-type, with adequate endowment, well-equipped laboratories, modern teachers devoted to medical investigation and instruction, and its own hospital in which the training of physicians and healing of sick persons combined to the optimal advantage of both.” It is considered the first, and the model for all later research universities. Johns Hopkins Medical School served as a model for the reorganization of medical education. After this, many sub-standard medical schools closed.
Medical schools had become mostly diploma mills, with the exception of a few schools in large cities. Two developments changed that. The first was the “Flexner Report,” published in 1910. Abraham Flexner was a leading educator who was asked to study American medical schools. His highly negative report and recommendations for improvement led to the closing of bad schools and the creation of standards of excellence for a real medical education.
The other development was Sir William Osler, a Canadian who was one of the greatest professors of medicine in modern history. He worked at McGill University in Canada, and then at the University of Pennsylvania, before being recruited to be the first physician-in-chief and one of the founders of Johns Hopkins University. There he established the first residency training and was the first to bring students to the patient’s bedside. Before that time, medical students learned from textbooks only until they went out to practice, so they had little practical experience. Osler also wrote the first comprehensive, scientific textbook of medicine and later went to Oxford as Regent professor, where he was knighted. He established patient-oriented care and many ethical and scientific standards.
By 1930, nearly all medical schools required a liberal arts degree for admission and provided a 3- to 4-year graded curriculum in medicine and surgery. Many states also required candidates who wanted to get their medical license to complete a 1-year internship in a hospital setting in addition to holding a degree from a recognized medical school.
American doctors did not begin to specialize until the middle of the 19th century. People who objected to specialization said that “specialties operated unfairly toward the general practitioner, implying that he is incompetent to properly treat certain classes of diseases.” They also said specialization tended “to degrade the general practitioner in the view of the public.” However, as the knowledge in medicine continued to grow and many doctors chose to do more of what they were interested in and good at, specialization became inevitable.
Economics also played an important role, because specialists typically earned higher incomes than the generalist physicians. The debates between specialists and generalists continue, and have recently been fueled by issues related to modern health care reform.
Medicine was the first of the professions to require licensing. State laws on medical licensing outlined the “diagnosis” and “treatment” of human conditions in medicine. Any individual who wanted to diagnose or treat as part of the profession could be charged with “practicing medicine without a license.” As a result of the strict licensing laws issued by the various medical societies, conventional Western medicine was able to establish itself in American health care.
SCOPE OF PRACTICE
practice of medicine includes the diagnosis, treatment, correction, advisement, or prescription for any human disease, ailment, injury, infirmity, deformity, pain, or other condition, physical or mental, real or imaginary.
MDs may be found within a wide range of practice settings, including private practices, group practices, hospitals, health maintenance organizations, teaching facilities, and public health organizations.
REGULATION OF THE PROFESSION
Medicine, like many other professions, is regulated at two different levels:
- Licensure is a process that takes place at the state level in accordance with specific state laws
- Certification is established through national organizations with consistent national requirements for minimal professional practice standards
Licensure: All states require that applicants for MD licensure be graduates of an approved medical school and complete the United States Medical Licensing Exam (USMLE) Steps 1 – 3. Steps 1 and 2 are completed while in medical school and step 3 is completed after some medical training (usually between 12 – 18 months, depending on the state). People who earned their medical degrees in other countries also must satisfy these requirements before practicing medicine in the United States.
With the introduction of telemedicine, there has been concern as to how to handle state licensure issues when medicine is being shared between states through telecommunications. Laws and guidelines are being addressed.
Certification: MDs who wish to specialize must complete an additional 3 – 9 years of postgraduate work in their specialty area, then pass board certification examinations. Doctors who claim to practice in one specialty should be board-certified in that specific area of practice.