THE LEGAL CONTROL OL MEDICAL PRACTICEA

STATE EXAMINATION.BY JOHN B. ROBERTS, M.D.,

PROFESSOR OF ANATOMY AND SURGERY IN THE PHILADELPHIA POLYCLINIC.

Read at the Fourth Stated Meeting of the Medical Jurisprudence Society, October 13th, 1884.

Reprinted from The Polyclinic, November 15th, 1884.

It is my intention this evening to briefly re-view the advantages that would accrue to thepublic and the medical profession by the enact-ment of a law placing the control of medicalpractice in the hands of a State Board of Ex-aminers. As is known to many of you, a per-son who desires to practice medicine in Ger-many must pass a governmental examination.The students study in universities, and takedegrees, but such degrees do not confer theright to enter upon practice. The health andlives of the citizens of the empire are believedtoo valuable to be imperiled by the acts ofignorant physicians. Hence, although the uni-versities themselves are under the supervisionof the State, the candidate for practice must, inaddition to his university examination for a de-gree, pass a govermental examination for licenseto follow professional work among the peopleof his vicinity. He is not a legally qualifiedpractitioner until this is accomplished.

The recklessness with which medical legisla-tion has been neglected in this State will beapparent when I say that the medical schoolsare under no State or Federal supervision what-ever. They have entire control of the time andcharacter of studies required from the intendingpractitioner, examine him upon the same, andconfer the medical degree, which is at onceaccepted by the authorities as evidence of suffi-cient knowledge and skill to entitle the possessorto practice medicine, surgery and obstetrics inthe community. Still further, to encouragewholesale and unrestrained manufacture ofphysicians, the “doctor manufactories” are, Ibelieve, even exempt from taxation.

Until the year 1881 there existed in this Com-monwealth no law whatever regulating medicalpractice. At that time the law to provide forthe registration of all practitioners of medicineand surgery was enacted by the General As-sembly of Pennsylvania. It effected much good,and was a distinct step forward, though it has,among other minor defects, the weakness thatthe possession of a genuine diploma is takenas evidence of knowledge.

As long as the medical schools of the UnitedStates are dependent for prosperity upon thenumber of fees received from pupils, and aslong as examinations by the faculties who re-ceive these fees are the sole test of skill, adiploma, even from the highest grade institution,carries with it little value as a diagnostic proofof professional learning. The old Latin pro-verb has it: “ Caveat emptor,” “Let the buyerbeware.” I say, “Caveat seger,” “Let the sickman beware,” if he believes that the fact ofgraduation from a renowned college confersintelligence and skill. The placard, “No rea-sonable offer declined,” usually tells the buyerthat inferior quality of goods is to be expected.Would that many colleges had the honesty todisplay a similar escutcheon over their portals,reading “No reasonable ignorance rejected.”

The step I advocate to-night is the creationof a Board of Medical Examiners, under Statejurisdiction, which shall examine all persons de-siring to enter upon practice in this State, afterJanuary Ist, 1886, without regard to when,where, or how they obtained medical education.If such an examination by non-interested per-sons shows the proper qualifications, the candi-

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date is to be furnished with a certificate, and isthen registered in the Prothonotary’s office asheretofore. Let the medical schools teach, ex-amine, and grant degrees as at present; butlet no one practice in this State who has notbeen examined by those who have no interestin passing or rejecting him. In other words,merely substitute for the diploma the certificateof the State Examining Board, as the requisiteof registration.

The greatest advantage derived from such alaw would be the protection of the public healthfrom ignorant physicians. Bear in mind that Irefer now, not to Indian medicine men, negroherb doctors and other charlatans, but to igno-rant physicians, graduates of recognized andreputable schools of the United States andother countries; such as are duly armed withbeautifully engraved diplomas signed by leadersof the profession, and, therefore, more danger-ous to the community than a whole tribe ofIndian “pow-wow-ers.”

The United States government long agoadopted a similar plan of examining candidatesfor its army and navy medical services ; so thatat the present time its soldiers and sailors, evenin distant territories and seas, have an averagebenefit of better educated physicians than citi-zens of New York, Philadelphia or Boston. Anarmy or navy surgeon receives his education inany school, but he enters the federal serviceonly after an examination by a board who hadnothing to do with teaching him, and who haveno pecuniary interest in passing ignorant can-didates.

A second advantage of the plan advocated isthe improvement in registration that would takeplace. By the present law, persons who werein continuous practice for ten years prior to itsenactment were allowed to register without di-ploma and without examination. Such persons,if any still reside in the State unregistered, orif any new ones come into the State, would bythe new law be required to show their qualifi-cations for practice by examination. Thiswould be a gain, as it would exclude a certainproportion of uneducated persons.

Section 4 of the Registration Law requirespersons coming into this State with diplomasfrom other countries or States, ‘‘to lay the samebefore the faculty of one of the medical collegesor universities of this commonwealth for inspec-tion, and the faculty, being satisfied as to thequalifications of the applicant and the genuine-ness of the diploma, shall direct the dean of the

faculty toendorse the same, after which such per-son shall be allowed to register.” This imposes aconsiderable amount of work upon the medicalschools, who, doubtless, would gladly be ex-cused from this unpaid and uncongenial labor;for to reject the diploma or graduate of a neigh-boring institution lays the school open to unjustcriticism. Moreover, the law does not state thatthe said colleges should be schools for under -

graduates. Some months ago application wasmade to me, as Secretary of the PhiladelphiaPolyclinic and College for Graduates in Medi-cine, for certification of a man’s qualificationsfor registration under this act. Undoubtedly,post-graduate medical schools were notintendedby the law, and I declined to act in the matter.Moreover, there are loopholes in the Registra-tion Law, by which punishment for practicingillegally can be escaped. A notable case oc-curred, six or seven months ago, in Clearfieldcounty, and is mentioned in an editorial pub-lished in the Polyclinic for March, 1884.

An exceedingly important result of the estab-lishment of a State Examining Board in Penn-sylvania would be the elevation of the standardof education in the medical colleges of thecountry. Many citizens and prospective citi-zens of the Keystone State study in the collegesof New York, Maryland, Ohio, Michigan andother States. As soon as it is known that noone can practice in this wealthy commonwealthunless he passes the State examination, suchpersons will study in the highest grade schools,and in those whose graduates show the smallestpercentage of failure before the PennsylvaniaExamining Board. Hence, if our schools arethe best equipped and supply the best educa-tion, men will not pay their money to theteachers, boarding-house keepers and mer-chants of other States, but will attend ourown schools, and thus increase the businessprosperity of Pennsylvania. The competitionof low grade colleges, whether in this or neigh-boring States, would not then tend to paralyzethe efforts of institutions of high educationalstandard. There would be no longer a pre-mium offered for quick graduation after twoyears’ study and a five minutes’ oral examina-tion in each of seven branches.

Another indirect advantage would be this:that students could study in several institutions,and thus gain the benefit of hearing the fore-most teachers of various schools, instead ofbeing cognizant with the precepts of but onefaculty. The former method of study is cer-

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tainly the most elevating, as it broadens profes-sional knowledge.

The division of labor resulting from exami-nations being held by a non-teaching board,having committees in different parts of the State,would make it possible to hold written andmanipulative, as well as oral examinations, andthus do better justice to candidates than is pos-sible by an oral examination alone. Again, theexaminations not being held all at one time ofyear, would further accommodate intendingpractitioners and lessen the labor of the exam-iners. As it is now, the college faculties, withgreat inconvenience to themselves, and oftenwith injustice to the pupils, hurry through theexaminations of several hundred students in afew days. A gentleman now dead, who wasfor years a professor in a large medical school,once told me of a case where a man who failedto pass his examination was actually graduated,because of a clerical error that occurred in thehurry of Commencement time. Neither of usknew how many people owed their deaths tothat accidental physician. Bright men mayhave been rejected by similar errors made inhasty examinations. The State Board exami-nation wouldbe conducted leisurely, and beingpartly written, would show by the recordswhether a man was unjustly rejected. Hewould also have the right to a public appealfrom the report of the Board, which now he hasnot. The college examination is, as it shouldbe under the present arrangement, the privatebusiness of a private corporation, and, there-fore, sealed from public inspection.

Another advantage which deserves considera-tion, is the power of revoking a man’s licenseto practice, which would be possible if a StateExamination Board is instituted. His diplomacannot and could not be taken away, but hiscertificate of knowledge, character, etc., couldbe canceled or withdrawn by the board if hewas convicted of criminal malpractice or similarcrime.

The last reason for advocating the law iscogent; but to my mind deserves little atten-tion, because it is a selfish one, which shouldinfluence us much less than those previouslydiscussed. Such an examination would weedout and keep out of the profession those per-sons who, though ignorant of medical science,accept professional duties and emoluments, andthus increase the difficulty of an educatedphysician gaining a livelihood. There are, un-doubtedly, too many physicians for the needs

of the closely settled districts. Fewer doctors,and better ones, would be a boon to most sec-tions of the State. The State examinationwould effect both objects. The legal professionhas, I believe, certain restrictions to indiscrimi-nate admission to the bar. Why should not themedical profession have some similar protection?

Dr. Isaac Ashe speaks of districts in Scotlandwhere sixpenny charges are made by physi-cians, and says he knows of an English townof 50,000 inhabitants, where one shilling chargesare made for medical advice. [“ Medical Poli-tics,” the Carmichael Prize Essay for 1873, P--33.] He quotes from the Medical Press andCircular, of September nth, 1872, p. 216, thefollowing charges adopted by a practitioner ofthirty years’ experience ; —“ Midwifery, twoshillings and sixpence; advice, sixpence; con-sultations, one shilling.” Is there a barrister inEngland, or an attorney-at law in Pennsylvania,who accepts such insignificant fees for profes-sional services ? Yet the position of the medicalprofession in Pennsylvania is little better thanthat mentioned in England. The poor esti-mate put upon medical service is due to theovercrowded state of the profession, and theinferior quality of much medical work; both ofwhich conditions would steadily decrease afterthe initiation of a State examination.

That the medical profession desires the adoption of a State Examining Board may be as-sumed from the recent action of the Philadel-phia County Medical Society. At a meeting ofthe present month, in which this and kindrededucational topics were fully discussed by col-lege professors, and practitioners, both generaland special, the following resolutions wereoffered. After postponement for printing andcirculation they were adopted :

Resolved, That the Philadelphia County Medi-cal Society believes that the status of themedical profession of this State will be elevatedby the establishment of a non-teaching Boardof Medical Examiners, wTiose certificate shallbe the only one accepted by the Prothonotary’soffice for physicians registering after January,1886.

Resolved, That the other county societies ofthis State be requested to advocate the estab-lishment of such a Board at the next meetingof the State Society, and to discuss the matter,prior to that meeting, with the members of theGeneral Assembly resident in their counties.

Resolved, That the Corresponding Secretarybe directed to transmit a copy of these resolu-tions to the Secretary of each county society,with the request that immediate action be taken,and reported to this society.

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Resolved, That a committee be appointed todraft a law creating a State Board of Examiners,for the examination of all persons for license topractice medicine, the said law to be presentedat the next meeting of the Medical Society ofPennsylvania by the Philadelphia delegates tothat meeting.

Having spoken of the advantageous actionof a State Examining Board, I must hastilyconsider the objections that will be raised to itsenactment.

It will be said that physicians living outsideof this State,but near its border, are often calledto attend patients in Pennsylvania. Very well;let them be examined by the PennsylvaniaBoard, and register in the county of this Statenearest their residences. Shall a physician ofNew Jersey, Maryland, Delaware, New Yorkor Ohio practice continuously in Pennsylvania,without being subjected to the same examina-tion as residents of this State ? Certainly not.Those, however, who come into the State asconsultants with duly licensed practitioners ofthis State should, of course, be excused fromthe State examination. So should dentists whodo not practice medicine, whether residents ornon-residents of the State. In the same man-ner midwives, who attend the very poor in casesof confinement, should be exempt from profes-sional examination, though they undoubtedly

should be registered and give some evidence ofobstetric knowledge.

A physician changing his residence withinthe State would merely be required to registerin his new locality, but would have to pass nosecond examination. Nor should those nowlegally registered and practicing be required to>pass the State examination.

It will be urged as an objection that thereare physicians who desire to practice specialsystems of medicine, and that such a Stateexamination would exclude these from practice.Not at all. Let the Board examine all candi-dates on anatomy, physiology, pathology, hy-giene, surgery, obstetrics, chemistry and materiamedica only, omitting theories of medical prac-tice and therapeutics entirely from the schedule.

I have thus advocated, Mr. President andgentlemen, a measure which will, I believe,add to the wealth and prosperity of the Stateof Pennsylvania and elevate the profession ofmedicine; for whatever elevates the latter mustincrease the former. The wealth of a commu-nity is the health and lives of its citizens. Everyuseful life saved, every illness shortened, addsto the public treasury. The educated physicianmay do both; the ignorant physician doesneither. I pray you to aid in cultivating theone and eradicating the other.

1118 Arch street.

Dear Doctor—A committee of the Medical Jurisprudence Society, in conjunction with a committee of the

Philadelphia County Medical Society, is preparing a bill on the above subject, for presentation tothe Legislature of Pennsylvania. It is hoped that the profession in general will lend assistancein this effort to elevate the standard of medical education. Yours, truly,

John B. Roberts.