Exploring Human Potential

A Debt of Gratitude to Former President Trump. Here’s why…

Posted on | March 30, 2023 | 6 Comments



Mike Magee

No man is above the law! That is the screaming headline behind last evening’s indictment (first of many) of former President Donald Trump. 

Donald Trump, for a time, sat himself in the middle of America’s triangle of power. From his seat as President, he installed himself as “a Golden Idol” and had a commanding view of the Executive branch of government. He then subverted the Justice Department and directed therm as a “strike force.” By aligning with the Federalist Society, the Christian Right and Mitch McConnell, he was able to stack the Judiciary and deliver a promised reversal of Roe v. Wade. But that federal overreach, which included rejecting  50 years of precedent and compromising women’s freedom and autonomy over their own bodies, fueled his undoing. It led to a resounding 2020 Trump defeat and Republican statewide under-performance in the 2022 Mid-term elections.

It also triggered a first ever President-led armed insurrection on January 6, 2021. But in a real-life “Democracy stress test,” this is the week when one of our three branches of government finally broke the spell and delivered a message to all Americans that no man is above the law.

Consider the record:

First, our citizenry pried the Executive branch free of Trump in 2020.

Second, our Judiciary, including state and federal courts, have rejected nearly 100 bogus cases led by unethical lawyers on Trump’s behalf, and have now indicted (for the first time in our nation’s history) a former President. Multiple indictments of a now, unprotected and disgraced Trump are certain to follow. Along the way,  hundreds of violent and disgraced fringe followers have been secured behind bars.

Third,  a Republican led Congress has been forced to cooperate on real issues in secrecy, while publicly feigning continued fealty to Trump and a small band of farcical Trump look-alike’s intent on driving their party over the cliff. With their hero now publicly indicted, expect this small band of  most ardent Congressional supporters to suddenly lose their voices. And as Trump losses mount, expect these actors to evaporate and slink back into the cracks of our society.

James Madison, author of Federalist No. 51,  predicted as much.

On February 8, 1788, he wrote: “If men were angels, no government would be necessary… the great difficulty lies in this: you must first enable government to control the governed; and in the next place oblige it to control itself.”

It has not been easy on any of us, and the job is not yet done. Our Judiciary has a complicated road ahead and must see it through. Our Congress must take lessons learned and advance legislation to curtail future Executive abuses and ensure that  voting access is secure in all fifty states. And the election of 2024 must lay the groundwork for reasserting women’s freedom and autonomy, sensible gun policy, and sound immigration policy.

But in the meantime, thank you, Donald Trump! Your service, in stress testing the durability and resilience of our Democracy, has been invaluable. Thanks to you, we have uncovered a range of weaknesses in our design, which we will correct.

But as important, we have stood up to you, a Bully and a Golden Idol, and in so doing have proven to each and every one of our citizens that “No man is above the law.”

Our Democracy for certain is a work in progress, but your place in history is permanently secured– the only President ever to be indicted in the history of the United States of America.

“If Men Were Angels…” American Democracy Will Pass This Stress Test.

Posted on | March 27, 2023 | No Comments

Mike Magee

As we enter a new and potentially historic week, with a former President doing his best to reignite a Civil War in our nation, we do well to take a breath and reread James Madison’s words from Federalist No. 51. But first, a few words of history.

When it came to checks and balances in this new national experiment in self governance, the Founders, while establishing three co-equal branches, left one of those branches the task of defining by practice its own power and influence.

The new Constitution in 1787 awarded one branch, the elected Congress, the daunting power to impeach, convict and remove representatives or appointed federal officials for due cause up to the President himself. But it also empowered a second branch, the Executive, through its President, veto power to check legislative excesses and the privilege of initiating appointments to the federal judiciary. Only the third branch of the government, the Judiciary, was left deliberately “elastic,” destined to grow into “the triangle of power.”

Thirteen years later, on February 17, 1801, Congress was forced to break a tie in the Electoral College vote, resolving a Constitutional crisis and declaring a victor in one of “the most acrimonious presidential campaigns” in U.S. history. Thomas Jefferson was awarded the victory, and John Adams acquiesced and was sent packing a month later. But two days before he departed, Adams unloaded multiple appointments of circuit justices and justices of the peace which the U.S. Senate quickly confirmed on March 3rd. In the rush, Adam’s Secretary of State, John Marshall (soon to become Chief Justice Marshall of the Supreme Court under President Jefferson) didn’t have time to complete a final necessary step, delivering the commissions, to some of the appointees.

When Jefferson took office on March 4th, and saw the opportunity to block some judgeships on the technicality, he instructed his new Secretary of State, James Madison, to not deliver the commissions. One of those prospective new judges, a Maryland businessman, William Marbury, after trying to unlock his commission for several months, filed a lawsuit in December, 1801 demanding that his commission be delivered through a “writ of mandamus.” ( “an order from a court to an inferior government official ordering the government official to properly fulfill their official duties or correct an abuse of discretion.”)

Eventually the case came to the Supreme Court and John Marshall delivered the unanimous verdict on February 24, 1803 in Marbury v. Madison. 

In short, William Marbury did not get his judgeship, but not because he didn’t deserve it. He did, and the decision said as much. But the Court also recognized that the authority that Section 13 of the Judiciary Act of 1789 had granted the Court to issue “writs of mandamus” (and effectively force Secretary of State Madison to deliver the appointment) was unconstitutional. 

This was because Article III of the U.S. Constitution  (signed September 17, 1787) made clear that the Supreme Court had “original jurisdiction over cases only where a U.S. state is party to the lawsuit.” As legal experts have explained: While the decision “limited federal court’s jurisdiction, it cemented the Court’s status as the ultimate interpreter of the Constitution.”

William Marbury’s loss became our nation’s gain. Our third branch of government, in finding its voice, defined its own powers. As Justice Marshall wrote “It is emphatically the province and duty of the Judicial Department to say what the law is…a Law repugnant to the Constitution is void.” As law historian Lawrence Friedman wrote, “Here for the first time John Marshall in the U.S. Supreme Court dared to declare an act of Congress to be unconstitutional.”

Donald Trump, for a time, sat himself in the middle of America’s triangle of power. From his seat as President, he installed himself as “a Golden Idol” and had a commanding view of the Executive branch of government. By aligning with the Federalist Society, the Christian Right and Mitch McConnell, he was able to stack the Judiciary and deliver a promised reversal of Roe v. Wade. But that federal overreach, which included rejecting  50 years of precedent and compromising women’s freedom and autonomy over their own bodies, fueled a resounding 2020 Trump defeat and Republican statewide under-performance in the 2022 Mid-term elections.

It also triggered a first ever President-led armed insurrection on January 6, 2021. But in a real-life “Democracy stress test,” this may be the week when our three branches of government finally deliver a message to all Americans that no man is above the law. 

First, our citizenry pried the Executive branch free of Trump in 2020. 

Second, our Judiciary, including state and federal courts, have rejected nearly 100 bogus cases led by unethical lawyers on Trump’s behalf, and are nearing multiple indictments of a now, unprotected and disgraced former President. 

Third,  a Republican led Congress has been forced to privately cooperate on real issues, while publicly feigning continued fealty to Trump and a small band of Trump look-alike’s intent on driving their party over the cliff.

So what did James Madison, author of Federalist No. 51, have to say about all this? 

On February 8, 1788, he wrote: “If men were angels, no government would be necessary. If angels were to govern men, neither external nor internal controls on government would be necessary. In forming a government which is to be administered by men over men, the great difficulty lies in this: you must first enable government to control the governed; and in the next place oblige it to control itself.”

Trump is a stress test, and our nation is rising to the challenge. We are gradually, slowly and painfully, learning to “control ourselves” by enforcing our laws. Democracy is a work in progress.

Deregulation – The Beginning and End of Silicon Valley Bank (1983 to 2023)

Posted on | March 22, 2023 | 4 Comments

Mike Magee

To know Silicon Valley Bank – SVP (prior to its dramatic demise) is to understand the world of tech start-up’s – their needs, appetite for risk, human behaviors, and the rapidly changing and dramatic world of technologic breakthroughs.

The bank itself was four decades old created in 1983, in Silicon Valley, for Silicon Valley. Before its collapse a few weeks ago, it was the bank of choice for almost 50% of all life science oriented tech companies launched by venture capitalists in the US.

Life science and health start-up’s were a specialty of SVB, and cornered 12% of its $173 billion in deposits. But these are unusual and challenging customers. They are married to “reverse lending.” That is to say, a health tech entrepreneur might show up on your door step with a big dream in a field where only 1 in 10 succeed, and open an account with $25 million in venture capital dollars in hand, and ask you to be their bank of record. They then begin immediately to draw down the money to realize their dream, which, if successful in early stages, will require raising much more money.

The SVP bankers, venture capitalists, and start-up entrepreneurs lived together in this risky, high-flying ecosystem and were committed to mingling with each other. As one of their clients said, “If you’re trying to raise money and you want to go to a conference and meet 100 investors, not five investors, that’s the place to go.”

But the Harvard Business types say that this type of non-diversified hyper-specialization, with its super-fast digital banking infrastructure, is exactly what allowed SVB’s “loyal customers” to withdraw $42 billion in assets in a single day, leaving it $1 billion in arrears. As HBS professor Paul Gompers wrote, “the hyperconnected nature of SVB’s clients meant that a run on the bank could happen virtually instantaneously.”

Arguably, SVP bankers and their elite bench of health-tech analysts knew the start-up business in this discipline from start to finish. Their website featured a range of products and services, assessment tools and strategic visioning that, on their own, justified the customer fees. But in addition, the bank understood that these customers had special needs in cash management and wealth management, VC relationship building, and lucrative transitioning into IPO offerings if they got that far.

Yet, as 2022 arrived, there were clouds on the horizon. SVP laid it out, but with rosy bracketing. In their lead, they wrote: “Dramatic shifts over the past nine months indicate that a market rebalancing is underway, with investments and valuations lowering from 2021’s boom. However, the healthcare industry is more resilient during periods of downturn and remains ripe for innovation.”

Their three key takeaways were:

1) “Investments are down but rebalanced from 2021 with shifts to earlier stages.”

2) “IPO window shut, but M&A on the rise…After a record 19 IPOs in 2021, market conditions and poor returns brought healthtech IPOs to a halt in 2022.”

3) “Mental health valuations and deal sizes up despite broader downturn.”

Still as the new year approached, and inside the bank, warning signals had begun to flash, SVP analysts, seeing AI taking off everywhere, banner headlined that “Virtual and Hybrid Care Are Here To Stay.”  As they saw it, “Now that virtual care is ubiquitous in 2022, investment is shifting to companies delivering quality outcomes. Mature alternative care companies must not only prove their profitability but also their ability to take on risk and accountability with buyers to deliver quality outcomes.”

Under the hood though, according to a Forbes report, issues dating back to Covid and 2019 had caught up with bank management. Forbes later reported that “From 2019 to the end of 2020, SVB’s assets, meaning loans, credit facilities, securities, and other investments grew 63%. And from 2020 to the end of 2021, total bank assets grew over 83%. This significant asset growth happened in years when Covid-19 caused death, illness, and lockdowns. Loans alone grew almost 114% from 2019 to 2020 and then almost 30% from 2020 to 2021…With a rise in assets comes more risk. What should have also caused eyebrows to raise was when risk weighted assets went up 13% at a time that asset size barely moved from 2021 to the end of 2022.”

What was missing here say experts wasn’t health sector chops but basic Banking 101: Gap Analysis – assessing a bank’s liabilities versus assets under various interest rate scenarios. Records now show that SVB losses in the fall of 2022 hit $100 million due to asset valuation decline. This triggered a bargain basement sale of $1 billion in securities on March 8, 2023, and the rest is history.

Not everyone was caught in the lurch. As Barron’s reported, SVP CEO Greg Becker unloaded 12,451 shares at $287.42 a share and pocketed $3.6 million. Adding insult to injury, the source of those shares were stock options exercised that day that were pegged at $105.18 a share. That was 2 weeks before the bank was shut down.

Adding to the irony, in a bipartisan move several years ago, Congress raised the monetary threshold for mandatory government stress testing in 2018 for medium size banks like SVP over the loud protests of Senate banking expert Elizabeth Warren. This type of predatory deregulation was (no doubt) applauded and all too familiar to many of SVP’s original health sector clients who remember as far back as 1980 (three years before SVP was launched) when Senators Bob Dole and Birch Bayh released government patents to NIH funded scientists triggering a new field – biotechnology. The full effect was captured 25 years later in a classic article in The Economist titled “Bayhing for blood or Doling out cash?” 

But as Forbes analyst Mayra Rodriguez Valladares suggested, what goes around comes around. Her last word:  “All those politicians and bank lobbyists who were successful at lowering liquidity stress requirements for banks under $250 billion assets must be very proud now. I sure hope that they go help all those depositors who cannot access their funds and those who will now be in the unemployment line, especially in California.”

AMA/PhRMA v. Federalist Society – Let The Witch Trials Begin!

Posted on | March 15, 2023 | 2 Comments

Mike Magee

The law is a funny thing. When British settlers first arrived on our eastern shores in 1607, their clergy-led bosses struggled to establish the rules while “clinging precariously” to life itself. Where did the rules come from in the decades that followed? Some were derived from folk law. Others were indigenous (unique to the new land and circumstances.) And others still evolved from ever-changing belief systems.

The land these settlers came from had lawyers who bridged the gap between an aristocracy that created the laws and a citizenry subjected to the laws. As for judges, they were recruited from the lawyers guild, a literal “bench” team. Cynics say that purposeful complexity and inaccessible language and syntax provided lawyers an “excuse for existing.”

As societies grew in size and complexity, the need for fresh settlers reinforced that the laws and ordinances should not be needlessly bloodthirsty, or in British parlance, “contrary or repugnant to the laws and statutes of this our realm of England.” And while most all acknowledged England as the source point for the law, the stubbornly independent colonists molded a wide range of different systems as varied as the many colonies that had been granted charters to operate.

But “stubbornly jealous of self rule”, as one expert explained, “colonial law was more a child of English law than a subordinate.” Power and privilege, and maintenance of the status-quo, was reinforced by those who made the law. In the fertile land rich colony of Maryland, for example, slaves were confirmed a “capital asset” able to be sold, gifted, and used as collateral for loans as early as 1671.

Bad laws beget worse laws. Take for example the fallout of the 1896 decision of Plessy v. Ferguson that, in establishing the policy of “separate but equal” sent our nation down a trail to apartheid. Should we have been surprised then that some years later, as Berkeley historian Leon F. Litwak recounted, one Will Mathis, a white man convicted of a capital crime, demanded that he not be forced to use the same gallows rope as had just been sullied by the neck of a black victim – so thorough and penetrating was the stain of that prior decision as to spawn a demand for segregation by execution.

Presidents throughout our history have been frequently disappointed with the decisions made by the judges they themselves appointed. That is likely not the case with Donald Trump, whose appointees (Neil Gorsuch/2017, Brett Kavanaugh/2018, and Amy Coney Barrett/2020) all carried the seal of approval of uber-conservative Federalist Society – a vast political network with chapters at 200 law schools with 10,000 student members and 65,000 lawyer members in 90 U.S. cities. Few were surprised by their role in overturning Roe v. Wade as part of the recent Supreme Court Dobbs v. Jackson Women’s Health Organization decision. Nor was it surprising when Clarence Thomas signaled on the day of the decision that this was just the beginning.

As suggested above, bad law(yers) beget worse law(yers). And that has proven to be the case in 2023. Back in the middle of Trump’s Federalist Supreme Court takeover, another lesser Justice received Senate approval. His confirmation hearing revealed that he was a Conservative Christian, anti-abortion warrior and the co-founder of the Fort Worth, Texas chapter of the Federalist Society. His name is Matthew Kacsmaryk. 

His back story includes his 17-year old sister’s traumatic teen pregnancy, birth and adoption of the child, followed by uber-conservatism ever since. The Amarillo Division of the US District of Northern Texas was chosen deliberately to argue a case sponsored by members of the Republican Governor’s Association for one reason, and one reason alone. Its only district superior court judge is Matthew Kacsmaryk. Judge shopping tactics have long to part of the Federalist Society’s playbook.

The case, which began this week asks the court to overrule the FDA which, in 2000, approved the safe and effective use of mifepristone as part of a two drug regimen to induce abortion. 53% of all US abortions were medication induced in 2022, up from 37% just five years earlier. The plaintiffs say the FDA should have never approved it and that they ignored serious side effects. The AMA and its Federation members, the Public Health community, and the FDA say that the drug, with two decades of use, has proven the regimen is safe up to 10 weeks gestation.

Pharma execs like Jeremy Levin point out that there is more at stake here than curtailing a small radical fringe element. In his words, “Here, you’re not just challenging the right for a woman to treat a pregnancy or to treat miscarriage; you’re also now challenging the primacy of the FDA to approve vast, important medicines that are critical to our society’s health, and that has a fundamental impact on the entire nation.”

Former FDA associate commissioner Marc Scheineson is a bit more blunt. He says, “This is probably round one of a 12-round heavyweight boxing match. You want the court to decide what drugs are safe and effective? Well, good luck to all of us.”

Legal historian, Lawrence Friedman, reminds us that “Life in the colonies was precarious at first…In the beginning, in tiny, starving, beleaguered settlements, there was nothing like a sophisticated notion of separation of powers. The same people made rules, enforced them, handled disputes, and ran the colony.”

The Federalist Society’s attempted coup, with its tiny Amarillo size outposts across the nation linked by the Internet and Puritan style passions, is looking to recreate a vertical network with exclusive, Jurist-directed control over rules and regulations for a resistant vast majority. That’s the kind of system that ultimately led to witches’ conflagrations in earlier times.

Wise law however is a “rational instrument” and “underlies all modern systems” We are on a slippery legal slope at the moment. We would do well to remember that “all modern societies are governed by and through laws.” 

Leaning In To Public Health Policy: Public Health as Nation Builder.

Posted on | March 8, 2023 | Comments Off on Leaning In To Public Health Policy: Public Health as Nation Builder.

Mike Magee

As Stanford Professor of Law, Lawrence M. Friedman, wrote in A History of American Law, “One hundred and sixty-nine years went by between Jamestown and the Declaration of Independence. The same length of time separates 1776 and the end of World War II.” 

During those very early years that preceded the formal declaration and formation of the United States as a nation, our various, then British colonies, fluidly and independent of each other, did their best first to survive, and then to organize into shared communities with codified laws and regulations.

For legal scholars, law (and lawyers) are often viewed as “rational instruments” and necessary evils. But for social historians, they are  “a study of social development unfolding over time” impacted by emotions, politics and real-time economics. At the core of the struggle is a clash between the rights of the individual and those of the collective community.

This clash of values has been playing out in full view over the past three years of the Covid pandemic. It is also why Public Health veteran and Washington Post columnist, Dr. Leana Wen, has come to a conclusion that “Public health needs a reset.” In her column this week she asked, “Whose rights are paramount? The individual who must give up freedoms, or those around them who want to lower infection risk?”

This battle between “individual liberty and communal good” is ancient and current at the same time, and still a source of conflict wherever and whenever humans attempt some version of “nation building.” In our current case, as Dr. Wen described, “Some viewed mask and vaccine mandates as a direct encroachment on bodily autonomy. Others preferred them because they helped people feel safer as they resumed daily routines.”

Part of the reset that Dr. Wen is suggesting for our American society involves Public Health resisting the instinct to over-simplify, and rather lean into complexity by addressing decision making at the interface of science and values. This redirects fear and wasted energy to the community’s unmet needs – common ground initiatives like preventive steps such as better viral monitoring of wastewater on the one hand, and addressing the unintended consequences of our Covid response initiatives such as massive drops in routine childhood immunizations for diseases such as measles.

It is useful to recall that we humans on these shores have come a long way. From the beginning on the shores of Virginia in 1607, these early wild settlements were essentially lawless – that is without laws. They also were wildly different in their dates of entry and their range of issues. Consider that more than 100 years separated the beginnings of the Massachusetts Bay colony and the colony of Georgia. And as historian Lawrence  Friedman noted, “The legal needs of a small settlement run by clergyman clinging precariously to the coast of an unknown continent were fundamentally different from the needs of a bustling commercial state.”

In these modern times, we still resist acknowledging our own history of enslavement and mass displacement and destruction of millions of individuals and their cultures. And yet, here we are together, doing our best to push back against the Governor DeSantis’s of the world who would halt our human progress. 

in many ways, the struggle to act in a civil and wise manner, that mines common values, and finds a balance between individual freedom and wise collective rules and regulations, remains our hill to climb. 

Public Health policy, debating it and formulating it, can help us get there. This is because it exists at the intersection of Law and Medicine. We should advantage this opportunity, and make the most of it.


The Most Important Builder of the House of Medicine You Never Knew.

Posted on | February 26, 2023 | Comments Off on The Most Important Builder of the House of Medicine You Never Knew.

Mike Magee

Medical History is just not fair. What other conclusion can you draw from the thousands of references and citations featuring Philadelphia physician Benjamin Rush and his wild ideas on how to heroically treat Yellow Fever in 1793, but likely never heard of Dr. John Henry Rauch. The former signed the Declaration of Independence but directly or indirectly contributed to many an unpleasant death.  The latter saved millions and helped the AMA and the AAMC find their way out of their post-Civil War professional wilderness.

Dr. Rauch’s career, its’ span and breadth, is startling. Born in Lebanon, PA in 1828, he received his Medical Degree from the University of Pennsylvania, and then opened a practice in Burlington, Iowa. He was there in 1850 for the birthing of the Iowa State Medical Society, and with their encouragement published (just five years after Iowa achieved statehood) the epic “Medical and Economic Botany of Iowa” listing 516 species, fully 23% of the known flora of the state today.

Two decades later, he was onsite in Chicago from October 8-10, 1871, when 3.3 square miles of Chicago burned to the ground taking 300 souls with it, and managed the emergency medical aftermath for the city. By then he was all too familiar with conflagration and disaster, having earned the  imprimatur of lieutenant-colonel from the Union Army as assistant medical-director of the famed Army of Virginia during the Civil War.

Knowing this, it is not too surprising that in 1866 he was focused on cemeteries, publishing the 68 page pamphlet, “Intramural Interments in Populous Cities and Their Influence Upon Health and Epidemics.” In it, he informs a surprised public on page 48 that  “…no grave can be dug at a greater depth than five feet the greater part of the year, and in point of fact, few or none are dug deeper than four feet without coming to water…” 

His appointment as the city’s first Sanitary Director followed a year later and advanced a remarkably futurist view that linked the ecology and environment of Chicago to human health. And by 1876, as incoming president of the now 4 year old American Public Health Association, he was poised to make, arguably, his major contribution – as unifier of the House of Medicine.

As Federation of State Medical Boards’ historians tell the story, “The individualism and anti-regulatory climate of the Jacksonian Era, combined with the democratization of medicine…contributed to the wholesale collapse of medical regulation in the first half of the 19th century.” Illinois had led the way in eliminating all requirements for medical licensure in 1826. Over the next decade or two fourteen other states had followed their lead. Into this void entered a relatively small group of physician activists focused on mobilizing their colleagues under the banner of a new organization, the American Medical Association in 1847. In striving for both autonomy and prestige, they created a schism by attempting to label a wide range of self-proclaimed herbalists, homeopaths and eclectic practitioners as “irregular doctors.”

The public seemed singularly unimpressed. As John S. Haller Jr., PhD, historian and author of American Medicine in Transition, 1830-1910,wrote, the public “remained indifferent to progress in pathology, new germ theories of disease, or…primitive ideas that ascribed ills to the influence of the stars, provided they were relieved of their pain and freed from the bonds of sickness.”

Into this highly politicized professional battle entered Illinois’s head of their newly established state Board of Health, one John Henry Rauch in 1977. He focused on mediating a dispute which was complicated. Competing schools of medicine were widely variable and multiplying at an alarming rate. Rauch identified 24 in his state alone that he deemed “not eligible for licensure.” Add to this that the speed of advances in medical science were unprecedented at the time, and medical schools like Johns Hopkins, Harvard and the Universities of Pennsylvania and Michigan were clamoring for consistent high standards for medical education and licensure. And finally, in the wake of the Rockefeller’s and Carnegie’s abuses in an increasingly industrialized and urbanized landscape, the need for governmental oversight and standards was now attracting popular support.

In 1878, Rauch set the standard by engineering the passage of the The Illinois Medical Practice Act of 1877 with the first ever requirement that licensure would be available only to those graduating from “approved schools” with new high standards for both pre-medical and medical education. 3,600 physicians in the state had not graduated from any medical school. Within a year of the law’s passage, 1,400 of them were gone. This, for the first time, linked the interests of medical schools and state licensure boards, with state medical societies bridging the gap.

Three years later, many of the states had once again embraced medical licensure. In 1890, two events reinforced an evolving national sentiment. First, Rauch organized and convened The National Confederation of State Medical Examining and Licensing Boards, convening its first national conference at that year’s annual AMA meeting. Its goal was clearly stated – to apply “uniform standards” for medical schools and licensing boards. Second, a new organization, the AAMC, with members from 22 medical schools convened, focused on raising standards for medical education. Initially agreeing on “a curriculum of two terms not occurring in the same year,” by 1905, they had embraced a 4 year curriculum.

With Rauch’s encouragement, by the time of the announcement of his death in the British Medical Journal, at age 65, 27 states had created  medical licensing and examination boards. The individual states continued to jealously support their prerogatives and resisted standardized reciprocity between all states. Instead they mirrored each others programs requiring a medical license “by virtue of a ‘satisfactory’ medical diploma and an examination by a state medical board.”

Within five more years, the AMA would establish its Council on Medical Examination, and the AMA and AAMC  aligned with each other on common medical education reform spanning the next century, but  beginning with the 1910 Abraham Flexner report.

But without Rauch they would have come up short. As the Federation of State Medical Boards historians correctly reminded us, “Voluntary associations such as the AMA and the AAMC, while potentially influential, lacked the authority to drive needed change. The only recourse was legislative. …As the duly constituted legal authority regulating the practice of medicine within each state or territory, the state medical boards were poised to accomplish what others could not.”

Ecology Rescued the AMA and Medical Professionalism Beginning in 1870.

Posted on | February 17, 2023 | 2 Comments

Mike Magee

The results of their 1851 survey of 12,400 men from the eight leading U.S. colleges had to be shocking. The AMA was only four years old at the time and being forced to acknowledge a significant lack of public interest in a physician’s services. This in turn had caused the best and the brightest to choose other professions. There it was in black and white. Of those surveyed, 26% planned to pursue the clergy, 26% the law, and less than 8% medicine.

It wasn’t that doctors with training (roughly 10% of those calling themselves “doctor” at the time) lacked influence. They had been influential since the birth of the nation. Four signers of the Declaration of Independence were physicians – Benjamin Rush, Josiah Bartlett, Lyman Hall, and Mathew Thorton. Twenty-six others were attendees at the Continental Congress. But making a living as a physician, that was a different story.

During the first half of the 19th century, the market for doctoring went from bad to worse. Economic conditions throughout a largely rural nation encouraged independent self-reliance and self-help. The politics of the day were economically liberal and anti-elitist, which meant that state legislatures refused to impose regulations or grant licensing power to legitimate state medical societies. Absent these controls, proprietary “irregular medical schools” spawned all manner of “doctors” explaining why 40,000 individuals competed for patients by 1850 – up from 5000 (of which only 300 had degrees) in 1790.

The ecology of 1850’s medicine couldn’t be worse. The marketplace was a perfect storm – equal parts stubborn self-reliance, absence of licensure to promote professional standards, diploma mills that showed little interest in scientific advancement, and massive unimpeded entry of low quality competitors. 

The legitimate doctors in those early days saw 5 patients on a good day. Horse travel on poor roads, and the absence of remote systems for communication, meant doctors had to be summoned in person to attend a birth or injury. And patients lost a day’s work to travel all the way to town for a visit of questionable worth. The direct and indirect costs for both doctor and patient were unsustainable. As a result, most doctors had multiple careers to augment their income.

What saved the newborn AMA and the future of medical professionalism in the mid-19th century wasn’t scientific progress or political enlightenment, but ecology – the relations of doctors and patients to one another and their surroundings.

At the turn of the century, in 1800, only 6% of Americans lived in towns with a population of 2,500. With westward expansion, Manifest Destiny, forced relocation of native Americans, and slavery supported cotton and tobacco, that percentage reached only 15% by 1950. But the arrival of railroads and telegraph, canals, improved roads and steamboats transformed America. By 1890, 37% lived in cities. And that included doctors. Beginning in 1870, there was an exodus of doctors to cities in excess of the general population. In 1870, there were 177 doctors per 100,000 in large cities. By 1910 the number had grown to 241 per 100,000.

Congregating doctors in cities was a mixed blessing for the profession. It made contact easier to execute, allowing numbers of patients seen in a day to double and triple. But it also meant that more doctors (of widely different quality) would be competing for the relatively few patients who possessed the resources to pay fees for services.

The invention of the telephone was equally transformative. The first recorded local telephone network was in New Haven, CT in 1877. Soon after the Capitol Hill Drugstore in Hartford, CT, was linked to 21 local physicians. Not to be outdone, two years later, Dr. William Worrell Mayo connected his farmhouse in Rochester, Minnesota to the Geisinger and Newton drugstore in town. This made remote prescribing, as well as patient communications for emergencies and scheduling possible.

The telephone would soon be a pivotal organizing tool for fledgling medical societies attempting to improve medical education while eliminating “irregular doctors.” In 1877, Illinois led the way in reinstating medical boards, licensing of medical schools and physicians, and acknowledging the AMA.

The AMA’s focus now was on the promotion of professionalism, especially prohibitions on advertisement, and improving medical education and public health through sanitation, pasteurization of milk, and soon enough – replacing manure producing horses with new motor cars. 

The AMA also wisely insisted that membership required physicians to first join their county and state medical branches. This created an AMA “Federation” with unprecedented geographic reach. In 1900, there were only 8,000 members. By 1910 the organization was 70,000 strong having captured 50% of all “regular” physicians.

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