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 distinct groups: the physicians, the surgeons, and the apothecaries.
Physicians were viewed as elite and usually held a university degree. Surgeons, in contrast, were typically apprenticed and hospital trained and often served the dual role of barber-surgeon. Apothecaries also learned their roles prescribing, making, and selling medicines, through apprenticeships and sometimes within hospitals.
This distinction between medicine, surgery, and pharmacy did not survive in colonial America. University-prepared MDs from England, upon their arrival in America, were expected to also perform surgery and prepare medicines. The class distinctions and snobbishness associated with physicians over surgeons quickly became diluted.
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 and, having survived numerous obstacles, remains the oldest medical society in the United States.
The regulation of medical practice, by examining and licensing practitioners, was initiated by professional societies through provincial legislatures as early as 1760. By the early 1800s, the establishment of regulations, standards of practice, and certification of doctors was firmly in the hands of the medical societies.
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 school of the Medical Society of the County of New York, founded March 12, 1807. Proprietary programs began to spring up everywhere and 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 numerous abuses within medical education, a national convention was held in May 1846. Proposals from that convention included the following:
- The creation of a national medical association
- The adoption of uniform higher educational standards for MDs, including suitable courses of premedical education
- A standard code of ethics for the profession
On May 5, 1847, nearly 200 delegates representing 40 medical societies and 28 colleges within 22 states and the District of Columbia convened and 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 was maintained and has grown to become a formidable organization capable of exerting a great deal of influence on issues related to health care within the United States.
Initial educational standards for MDs, set by the AMA, included the following:
- A liberal education in the arts and sciences
- A certificate of training completion from the preceptor over apprenticeship prior to medical-college entrance
- An MD degree that encompassed 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 incorporate additional 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, two 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 primary force in establishing Provident Hospital, which still serves Chicago’s South Side.
Elizabeth Blackwell (1821-1920), upon 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.” Johns Hopkins Medical School served as a model for the reorganization of medical education.
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. In addition, many states also required candidates for medical licensure to have completed a 1-year internship in a hospital setting in addition to possessing a degree from a recognized medical school.
The emergence of specialization within American medicine did not take root 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” and that specialization tended “to degrade the general practitioner in the view of the public.” However, as the base of knowledge within medicine continued to grow and many doctors chose to do more of what they were interested in and good at, specialization became inevitable.
Economics may have also played an important role as the specialists typically enjoyed higher incomes than did 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 licensure. State laws specific to the licensure of medicine outlined the activities of “diagnosis” and “treatment” of human conditions strictly within the domain of medicine. Any individual who professed to “diagnose” and/or “treat” as part of his/her profession could therefore be charged with “practicing medicine without a license.” As a result of strict licensure laws that were promulgated by the various medical societies, conventional “Western” medicine was able to establish itself as a monopoly over the health care of the American populace.
SCOPE OF PRACTICE
The 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 a national organization(s) with requirements for minimal professional practice standards being consistent nationally.
Licensure: All states require applicants for MD licensure to be graduates of an approved medical school and complete the USMLE (United States Medical Licensing Exam) 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 obtained their medical degress in other countries also must satisfy these requirements before practicing medicine in the Unted States.
With the inception 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 to 4 years of postgraduate work within their area of specialty and then pass board certification examinations. Doctors who claim to practice within one of the specialties should therefore be “board certified” within that specific area of practice.
by Janet G. Derge, M.D.
All ArmMed Media material is provided for information only and is neither advice nor a substitute for proper medical care. Consult a qualified healthcare professional who understands your particular history for individual concerns.