August 7, 2025 • 19 mins
Provides a historical overview of the professionalization of medicine in the United States, focusing on the crucial role of state-level licensing laws and their ultimate validation by the U.S. Supreme Court. It highlights the intense conflicts and debates surrounding the regulation of medical practice, particularly the struggle between "Regular" physicians advocating for science-based education and licensing, and those who favored alternative medical approaches or less formal training. The text details the establishment and assertive actions of the West Virginia Board of Health and the landmark Dent v. West Virginia Supreme Court case, which affirmed the state's authority to regulate medical practice and ultimately shaped the legal landscape for medical licensing across the nation, leading to a system of preparation-only licenses that fundamentally transformed the medical profession.
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You can listen and download our episodes for free on more than 10 different platforms:
https://linktr.ee/book_shelter
Get the Book now from Amazon:
https://www.amazon.com/Licensed-Practice-Supreme-American-Profession/dp/1421411423?&linkCode=ll1&tag=cvthunderx-20&linkId=3bfd63888cb23743d60a55ae51b9ab85&language=en_US&ref_=as_li_ss_tl
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:00):
Welcome curious listeners to the Deep Dive. Okay, picture this
for a second. It's a chilly Saturday morning, March seventh,
eighteen ninety one. We're in downtown Wheeling, West Virginia. Streets
are bustling, you know, the usual Saturday morning vibe. And
then two men cross paths. Doctor George Garrison, he's thirty nine,
and doctor George Baird, older sixty two. These aren't just
(00:21):
any doctors. They're like the most well known physicians in
the city, celebrated guys. What happens next is just shocking.
There's a quick, harsh exchange, just a few words, and
then Garrison pulls out a pistol fires two shots point
blank at doctor Baird.
Speaker 2 (00:35):
It's incredibly dramatic. One bullet hits his skull, actually exits
near his eye. The other goes right into his chest,
severs a major artery.
Speaker 1 (00:42):
And here's the part that's almost unbelievable. Baird bleeding heavily,
He staggers into a store nearby. He actually takes off
his gloves, very calmly, and just tells the shot keepers.
Doctor Garrison shot me just like.
Speaker 2 (00:52):
That, and then he died maybe twenty minutes later. Incredible composure.
Really Yeah.
Speaker 1 (00:56):
Meanwhile, Garrison out on the street, he turns to someone,
says it's done, then just walks calmly to the police
station and surrenders, tells the officer it's done.
Speaker 2 (01:09):
Wild, just wild.
Speaker 1 (01:10):
But here's the twist. This wasn't just some personal feud
boiling over, though clearly it was intense. This was the climax,
the really bloody end of years of bitterness over something
that sounds well, incredibly dry, medical licensing exactly.
Speaker 2 (01:27):
And that's what's so fascinating here, this one violent act.
It really highlights the intense stakes, the deep emotions tied
up in this massive shift in American medicine. We're talking
about the change from this wide open anybody can be
a doctor, a kind of market, to the licensed professional
system we basically take for granted today.
Speaker 1 (01:43):
It wasn't just some abstract policy debate then.
Speaker 2 (01:46):
Not at all. It was life and death literally as
we just saw, but also figuratively for people's livelihoods and
the future of healthcare.
Speaker 1 (01:52):
Okay, so let's really dig into this today. We're diving
deep into that story. It's surprising, it's chaotic, it's definitely human.
We're exploring how American medicine went from that open field
to the highly regulated profession you encounter every time you
see a doctor. We'll cover the bitter fights, the strange alliances,
and this really crucial Supreme Court case that basically set
(02:15):
the foundation.
Speaker 2 (02:16):
Yeah, we'll look at that whole era before licensing was
a given. Why did people even want it, What were
the arguments, and what were the consequences, the ripples that
still affect how we think about healthcare quality and who
gets to be a doctor. It's a story baked into
our modern system.
Speaker 1 (02:32):
So let's go back. Try to imagine a time when
choosing a doctor wasn't about checking credentials online. It was
more like, well, maybe hiring someone to fix your wagon,
but maybe even less regulated than that.
Speaker 2 (02:44):
That's a good way to put it. Until the eighteen seventies,
states were really hesitant. They experimented a bit, but slowly.
There wasn't this automatic assumption that licensing was a good
thing or even helpful.
Speaker 1 (02:55):
And legally it was complicated too.
Speaker 2 (02:57):
Right absolutely, because under the Constitution, these kinds of laws
they had to be state by state. There was no
sederal bodies saying, okay, everyone needs a license for most
of the eighteen hundreds. Medicine was seen as a reserved power.
It was up to each date to decide if and
how they wanted to handle it.
Speaker 1 (03:13):
And for most people, day to day healthcare wasn't even
about doctors.
Speaker 2 (03:17):
Not really. Most folks relied on home remedies, maybe a
self help book, family knowledge. You called a physician for
something serious, something that wouldn't go away.
Speaker 1 (03:26):
So when you did need one, what were you faced with.
Speaker 2 (03:29):
A huge, kind of bewildering range of choices. Yeah, most
practitioners weren't mds from fancy colleges. They learned through apprenticeships,
and the quality the ideas they varied wildly. You could
get totally opposite advice from two doctors in the same town.
Speaker 1 (03:44):
And they weren't all full time doctors either.
Speaker 2 (03:46):
No, many practice part time, had other jobs and getting
paid well, unpaid bills were just part of the landscape,
very common.
Speaker 1 (03:53):
Okay. So in this mix you had the group known
as the regulars.
Speaker 2 (03:56):
Who were they, right, the regulars. These are the physicians
trying to follow classical medical theories. They formed state societies.
They were trying to embrace science aligned with what became
the AMA.
Speaker 1 (04:08):
But they weren't alone. There were lots of alternatives that
your regular oh yeah, a whole skeptrum.
Speaker 2 (04:12):
You had Tomsonians, they were big on herbal remedies, kind
of a do it yourself approach, botanics who were more
trained herbalists, hydropaths all about water cures, and then the
really big ones homeopaths using deluded remedies, surprisingly popular even
with educated folks.
Speaker 1 (04:29):
Really, homeopaths were popular with the.
Speaker 2 (04:31):
Elite, yeah they were. And then you had the eclectics.
They were kind of open to anything except harsh chemicals,
preferred gentle herbs, rest plus just countless others who weren't
really organized, eye doctors, cancer doctors, people calling themselves Indian doctors,
faith healers, bone setters, midwives, and tons of mail order
(04:52):
cures promising everything under the sun.
Speaker 1 (04:54):
So it really was a free for all. Why didn't
the regulars who thought they were the real doctors just
get laws passed to shut everyone down?
Speaker 2 (05:00):
They wanted to, right, they definitely wanted to. They called
the others dangerous, Charlatans, quacks. But here's the key thing.
They couldn't prove they were better. They couldn't prove it,
not objectively, especially for internal medicine. State legislators weren't convinced.
In fact, during epidemics in the eighteen forties fifties, the
homeopaths sometimes had.
Speaker 1 (05:21):
Better outcomes, no kidding, why was that.
Speaker 2 (05:23):
Well, the regulars were still doing a lot of harsh treatments, bleeding, purging,
strong emetics. Sometimes these treatments were arguably more dangerous than
the disease. So you couldn't just walk into the state
house and say our science is better when the results
didn't consistently back it up.
Speaker 1 (05:39):
So it wasn't just about science versus quackery. It was murkier,
much murkier.
Speaker 2 (05:45):
And the regulars, honestly, they developed this attitude that the
public was just too gullible and ignorant to see the truth.
Their belief was almost well religious. They felt the public
had to be forced by law to accept scientific medicine
for their own goods.
Speaker 1 (06:00):
That's quite an attitude, it is, and the result.
Speaker 2 (06:03):
By the time the Civil War started in eighteen sixty one,
there were basically no effective medical licensing laws anywhere in
the US. It truly was the wild West, Okay.
Speaker 1 (06:11):
So after the Civil War things start to shift. The
regular physicians they try again and West Virginia, this brand
new state born out of the war, becomes kind of
a test case right exactly.
Speaker 2 (06:22):
It's politics were still fluid, less entrenched. It presented this
unique window an opportunity for the regulars.
Speaker 1 (06:28):
And this is where the Medical Society of West Virginia,
the MSWV comes in right.
Speaker 2 (06:33):
Founded in eighteen sixty seven by a small group of
elite educated regulars led by doctor James Reeves. Reeves was
absolutely convinced about the need for formal scientific education. He
saw the MSWV as the true church of medicine. Their
goal was clear, were strict practice to those they deemed
professionally worthy, meaning formal degrees following AMA guidelines.
Speaker 1 (06:53):
But it wasn't smooth sailing even for them.
Speaker 2 (06:56):
Not at all. There were internal splits. Southern doctors, former Confederates,
felt excl luted by the Northern leadership, and membership was tiny.
Less than ten percent of the doctors in the state joined.
Why so few, well, many regulars themselves were apprentice trained.
They worried that strict licensing, demanding formal degrees would push.
Speaker 1 (07:13):
Them out to interesting so even within the regular camp
there was fear about these new standards definitely.
Speaker 2 (07:19):
But the leaders like Reeves and his key ally, doctor
George Baird. Yes, that doctor Baird. They were relentless. Baird
was a big deal Civil War veteran former mayor of Wheeling,
politically savvy. In their speeches, they'd rail against quackery and
medical sinners, very strong language.
Speaker 1 (07:36):
But did they ever actually show evidence, like specific stories
of patients being harmed by these other practitioners.
Speaker 2 (07:42):
That's the really interesting part. No, not really. Their arguments
were based on conviction, on the belief in science, almost
like a faith. They didn't present case studies of harm
from irregulars. They just asserted that their way was the
only right.
Speaker 1 (07:54):
Way, and they still believe the public needed to be forced.
Speaker 2 (07:57):
Yes, Their view was the public just didn't get it,
couldn't appreciate science, and needed the law to guide them
for their own good. You know.
Speaker 1 (08:04):
So by the late eighteen seventies they decide persuasion isn't working.
Time for Plan B exactly.
Speaker 2 (08:11):
They realized they need the state's power, so they pivot.
They start pushing for a state board of Health.
Speaker 1 (08:16):
Ah, the public health angle smart.
Speaker 2 (08:19):
Very smart. They used the fear of epidemics, something everyone
could understand as a stalking horse a cover for their
real goal, licensing. They knew anti abortion bills, which the
AMA also pushed, hadn't worked for getting licensing clauses passed.
Public sanitation was a better bet.
Speaker 1 (08:37):
And doctor Baird, the well connected one he leads this charge.
Speaker 2 (08:40):
Yes, he uses his political skills, his business connections railroads
were big, and his general popularity. Remember he often didn't
bill poor patients, which made him well liked. He gets
support from key figures like James Ferguson, a major corporate
lawyer and Democratic Party boss.
Speaker 1 (08:56):
Why would a corporate lawyer care about medical licensing?
Speaker 2 (08:59):
Ferguson's saw parallels. He believed in consolidation at the top,
whether in industry or professions. Just like big corporations brought order,
scientifictly trained doctors should bring order to medicine. It fit his.
Speaker 1 (09:10):
Worldview, So this alliance works.
Speaker 2 (09:12):
It does. In eighteen eighty one, the Board of Health
Act passes. Reeves wrote the bill. Ferguson helped push it through.
There was opposition, mind you, anti monopoly democrats representing farmers
and laborers saw it for what it was, an attempt
by the allopaths the regulars to create a monopoly.
Speaker 1 (09:29):
But the key part got in the part about who
could be on the board.
Speaker 2 (09:33):
Absolutely crucial. The law stated all board members had to
be graduates of reputable medical colleges with twelve years experience.
That effectively locked out everyone else.
Speaker 1 (09:43):
And the governor appoints the board.
Speaker 2 (09:44):
Governor Jackson A. Reeve's ally appoints only staunch regulars, Reeves himself,
Andrew Barbie, who fought for it in the Senate, all
Ama alliganed guys Reeves even bosaid all members belonged to
the true Church in medicine. No subtlety there.
Speaker 1 (09:58):
Okay, So the board is in play, stacked with regulars.
What do they do first?
Speaker 2 (10:02):
They immediately start setting precedents. They hold exams for some
apprentice trained regulars, carefully handpicked ones, including George Garrison, Barrett's protege.
He passes, gets his license, Remember that detail.
Speaker 1 (10:13):
Uh huh. But things get tricky when others try to
get licensed, like the Dent family.
Speaker 2 (10:17):
Right, this is where it gets really contentious. First, Arthur Dent,
he was actually an MSWV member, but a bit of
a radical thinker. He questioned aggressive treatments, believe more of
the body's natural healing power. He didn't have a degree
or ten years practice, so he failed the board's exam.
Speaker 1 (10:34):
So what did he do?
Speaker 2 (10:35):
He quickly got an MD from a place called Columbus
Medical College, which apparently waived residency for him. Controversial. The
board was furious. They declared the college disreputable based on
new strict criteria they just drafted basically AMA standards, two
full years of study, labs, et cetera.
Speaker 1 (10:53):
And they rejected his degree.
Speaker 2 (10:55):
Flat out rejected it. Arthur eventually just gave up and
left West Virginia.
Speaker 1 (10:58):
Okay. Then there was his cousin, Frank Dent.
Speaker 2 (11:01):
Frank Dent, also apprentice trained from a family of doctors.
His own father had been MSWV president, actually arguing for
a more inclusive approach. Frank initially got a license under
a ten year grandfather clause, but Reeves suspected fraud. Thought
the clause was meant for Frank's elderly bedridden grandfather, not
Frank himself.
Speaker 1 (11:18):
So Reeves is suspicious. What does Frank do?
Speaker 2 (11:21):
Frank goes and gets an MD from an eclectic medical college,
the American Medical Eclectic College or AME. The board unanimously
rejects that too, calls amec not reputable, and they threatened
to prosecute Frank criminally if he keeps practicing.
Speaker 1 (11:35):
Wow, so Reeves is really playing hardball now, Oh yeah.
Speaker 2 (11:38):
He's board secretary, he's MSW president. He basically boasts about it, saying,
only through this kind of very great authority can they
force reform. He's drawing a line in the sand.
Speaker 1 (11:49):
So Frank Dent gets indicted for practicing without the board's approval.
And his lawyer is his cousin, his.
Speaker 2 (11:55):
Cousin, Marmaduke Dent. And Marmaduke is not just any lawyer.
He's a rising star in the anti miniomply wing of
the Democratic Party, a future West Virginia Supreme Court justice
known for defending the poor. This is setting up for
a major legal fight.
Speaker 1 (12:08):
What was Marmaduke's argument in court?
Speaker 2 (12:11):
He had heard. He argued the law was unconstitutional, a
sham designed purely to create a monopoly for the regulars.
He called it an expost facto law punishing Frank for
practicing when it had been legal. He argued it violated
inalienable rights.
Speaker 1 (12:24):
And he brought up this idea of medical practice as property.
Speaker 2 (12:27):
Yes, that was key, He argued, practicing medicine was a
form of property and the state couldn't just take it
away without due process. He cited older cases involving lawyers
who lost their right to practice, and he didn't pull punches.
He accused Reeves on the Board of selfishness, arrogance, and egotism.
Said their goal was to shut out competition, raise their fees,
(12:49):
increase their wealth, and give themselves political prominence. Strong stuff.
Speaker 1 (12:54):
How did the West Virginia Supreme Court respond to that?
Speaker 2 (12:57):
They sided with the state in eighteen eighty four. They
upheld the law. They bought the argument that this was
a valid use of the state's police power to protect
public health.
Speaker 1 (13:06):
Frank Gent lost, so the Board feels vindicated.
Speaker 2 (13:09):
Absolutely. Reeves and the Board push even harder. They grant
fewer licenses based on exams, focusing almost entirely on graduates
from reputable, meaning AMA approved schools. They're tightening the screws.
Speaker 1 (13:22):
And then comes that weird twist with George Garrison getting
appointed to the board.
Speaker 2 (13:25):
Isn't that something? Governor Wilson appoints Garrison to the board
even though Garrison himself got his MD in only seven
months from a school usually required.
Speaker 1 (13:33):
Two years, so his credentials weren't exactly stellar by the
board's own new standards.
Speaker 2 (13:37):
Not at all, and the MSWV saw it as a
political job, highlighting the Board's earlier inconsistency. Remember, Garrison passed
that very trivial exam back in eighty one, while the
Dents were rejected.
Speaker 1 (13:50):
So as the politics involved, did the courts ever waiver
any second thoughts?
Speaker 2 (13:54):
Nope. In eighteen eighty eight, the West Virginia Supreme Court
upheld the Board again in a case called State v. Ragland.
They admitted the law was maybe crudely drawn, but they
weren't going.
Speaker 1 (14:03):
To interfere, which leads us to the biggest stage of
all Frank Dent appeals again.
Speaker 2 (14:08):
He takes it all the way to the United States
Supreme Court Dent v. West Virginia. This is the ultimate
showdown eighteen eighty nine. The fate of medical licensing in
America really hangs in the balance.
Speaker 1 (14:19):
Marmaduke makes his case again property rights, due process he.
Speaker 2 (14:22):
Does, but the Supreme Court unanimously sides with West Virginia.
Justice Stephen Field wrote the opinion unanimous.
Speaker 1 (14:30):
Wow, what was their reasoning? This seemed like a big
shift from protecting economic rights.
Speaker 2 (14:34):
It was, and that's why it was kind of confusing
to legal folks at the time. Justice Field essentially carved
out an exception for medicine. He said, medicine isn't like
ordinary advocations. It's subtle and mysterious, and the public is
vulnerable to ignorance and incapacity. Therefore, the state needs to
protect them. He basically said, the state can make a
(14:55):
policy wager. It can bet on one approach, in this case,
scientific educated physicians, even if it means destroying the property
the practices of existing doctors who don't neet the new standard,
and it can do this without the kind of due
process you might expect for other property.
Speaker 1 (15:11):
So the state gets to pick winners, essentially in the
name of public health.
Speaker 2 (15:15):
That's the core of it. It gave states the constitutional
greenlight to say, we believe this type of preparation leads
to better outcomes, so we're limiting practice to those who
have it, even without definitive proof of better outcomes at
the time, and even if it harmed existing practitioners.
Speaker 1 (15:31):
This sounds like the birth certificate for the modern medical license.
What did it actually create, this preparation only license.
Speaker 2 (15:37):
It created a system where doctors could use the state's
power to control entry into the profession who gets to
be a doctor based solely on their initial training and credentials.
But and this is crucial, it didn't come with scrings
attached regarding ongoing performance or public accountability, meaning meaning no
state mandated fee gaps, no requirement to serve under ser areas,
(16:01):
and critically no requirement for continuing education or any system
to monitor how well doctors actually practiced after they got
the license.
Speaker 1 (16:09):
So the focus was all on getting the license, not
on what happened afterwards. If the goal was protecting the public,
that seems incomplete.
Speaker 2 (16:16):
Massively incomplete, and you could argue it ironically helps hide
problems for a long time. Think about it. If the
license is mainly about initial preparation, there's less focus on
ongoing confidence. It took decades, really, until reports like the
Institute of Medicines in nineteen ninety nine to highlight the
huge numbers of preventable medical errors happening within the licensed system.
Speaker 1 (16:36):
That report estimated what almost one hundred thousand deaths a
year from hospital mistakes, up.
Speaker 2 (16:40):
To ninety eight thousand deaths. Yes, and licenses were almost
never revoked for poor care, mostly just for criminal acts
or maybe substance abuse. The system wasn't built to track
or address routine clinical.
Speaker 1 (16:53):
Performance, so didn't force states to only license AMA style doctors,
but it allowed it exactly.
Speaker 2 (17:00):
It opened the door constitutionally, and predictably, the AMA regulars
walked through it. They came to dominate the state licensing boards,
and from that position they influenced everything. Medical school curricula, internships,
specialty certifications, all largely on their terms.
Speaker 1 (17:14):
Which leads to consolidation inexorably.
Speaker 2 (17:17):
In West Virginia. The final step came in nineteen twenty one,
a new law required all applicants to have degrees from
schools specifically approved by the AMA. Game over for the alternatives.
Speaker 1 (17:26):
Really, and that Struccher born in these battles is basically
the foundation of the healthcare system we have now, the
good and perhaps some of the bad.
Speaker 2 (17:33):
Absolutely the incredible advances, the high standards of training, but
also some of the issues around access, cost and maybe
insufficient focus on ongoing quality assurance. It all has roots
back here.
Speaker 1 (17:44):
Okay, before we wrap up, let's quickly go back to
where we started Wheeling eighteen ninety one. What happened to
doctor Garrison after he shot doctor Baird.
Speaker 2 (17:52):
The Great Doctor's Murder case, as the papers called it,
dragged on for two years, multiple trials. What was the
defense provocation? Garrison's lawyers argued that Baird had relentlessly taunted
and threatened him, pushing him past his breaking point. Remember
Baird was Garrison's former mentor. Then they fell out, possibly
linked to that board appointment controversy. After one mistrial and
(18:15):
one hung jury, Garrison was finally convicted, but only of
involuntary manslaughter.
Speaker 1 (18:20):
Involuntary after shooting him twice.
Speaker 2 (18:23):
Seems light, doesn't it. He was sentenced to on these
seven more months in jail he'd already served fifteen awaiting
trial and a two hundred and fifty dollars fine.
Speaker 1 (18:30):
Wow, a rather small PostScript to such a huge historical shift.
Speaker 2 (18:34):
A very small, sad personal consequence of this much larger
battle over who gets to control medicine.
Speaker 1 (18:40):
So the next time you find yourself in a doctor's office,
maybe take a second to think about the history behind
that license on the wall. It wasn't a simple linear
path to scientific truth. It was a fight about power,
about money, about different ideas of healing, and ultimately about
the state making that policy wager.
Speaker 2 (18:58):
And that Dent decision, It really cemented the state's power
to choose one model, the academically defined preparation focus model,
even if it meant pushing other approaches aside and creating
a system where performance wasn't tracked nearly as closely as preparation.
Speaker 1 (19:16):
Which leaves us with a final thought to chew on.
In our system today, built on Dent and everything that followed,
how much do we still emphasize that initial preparation, the degree,
the boards, the license, compared to tracking and ensuring ongoing
real world performance and the incredibly complex field of medicine.
Speaker 2 (19:32):
Yeah, where is that balance now? And what are the
potential costs to you the patient? If that balance isn't
quite right? Something to think about.
Welcome curious listeners to the Deep Dive. Okay, picture this
for a second. It's a chilly Saturday morning, March seventh,
eighteen ninety one. We're in downtown Wheeling, West Virginia. Streets
are bustling, you know, the usual Saturday morning vibe. And
then two men cross paths. Doctor George Garrison, he's thirty nine,
and doctor George Baird, older sixty two. These aren't just
(00:21):
any doctors. They're like the most well known physicians in
the city, celebrated guys. What happens next is just shocking.
There's a quick, harsh exchange, just a few words, and
then Garrison pulls out a pistol fires two shots point
blank at doctor Baird.
Speaker 2 (00:35):
It's incredibly dramatic. One bullet hits his skull, actually exits
near his eye. The other goes right into his chest,
severs a major artery.
Speaker 1 (00:42):
And here's the part that's almost unbelievable. Baird bleeding heavily,
He staggers into a store nearby. He actually takes off
his gloves, very calmly, and just tells the shot keepers.
Doctor Garrison shot me just like.
Speaker 2 (00:52):
That, and then he died maybe twenty minutes later. Incredible composure.
Really Yeah.
Speaker 1 (00:56):
Meanwhile, Garrison out on the street, he turns to someone,
says it's done, then just walks calmly to the police
station and surrenders, tells the officer it's done.
Speaker 2 (01:09):
Wild, just wild.
Speaker 1 (01:10):
But here's the twist. This wasn't just some personal feud
boiling over, though clearly it was intense. This was the climax,
the really bloody end of years of bitterness over something
that sounds well, incredibly dry, medical licensing exactly.
Speaker 2 (01:27):
And that's what's so fascinating here, this one violent act.
It really highlights the intense stakes, the deep emotions tied
up in this massive shift in American medicine. We're talking
about the change from this wide open anybody can be
a doctor, a kind of market, to the licensed professional
system we basically take for granted today.
Speaker 1 (01:43):
It wasn't just some abstract policy debate then.
Speaker 2 (01:46):
Not at all. It was life and death literally as
we just saw, but also figuratively for people's livelihoods and
the future of healthcare.
Speaker 1 (01:52):
Okay, so let's really dig into this today. We're diving
deep into that story. It's surprising, it's chaotic, it's definitely human.
We're exploring how American medicine went from that open field
to the highly regulated profession you encounter every time you
see a doctor. We'll cover the bitter fights, the strange alliances,
and this really crucial Supreme Court case that basically set
(02:15):
the foundation.
Speaker 2 (02:16):
Yeah, we'll look at that whole era before licensing was
a given. Why did people even want it, What were
the arguments, and what were the consequences, the ripples that
still affect how we think about healthcare quality and who
gets to be a doctor. It's a story baked into
our modern system.
Speaker 1 (02:32):
So let's go back. Try to imagine a time when
choosing a doctor wasn't about checking credentials online. It was
more like, well, maybe hiring someone to fix your wagon,
but maybe even less regulated than that.
Speaker 2 (02:44):
That's a good way to put it. Until the eighteen seventies,
states were really hesitant. They experimented a bit, but slowly.
There wasn't this automatic assumption that licensing was a good
thing or even helpful.
Speaker 1 (02:55):
And legally it was complicated too.
Speaker 2 (02:57):
Right absolutely, because under the Constitution, these kinds of laws
they had to be state by state. There was no
sederal bodies saying, okay, everyone needs a license for most
of the eighteen hundreds. Medicine was seen as a reserved power.
It was up to each date to decide if and
how they wanted to handle it.
Speaker 1 (03:13):
And for most people, day to day healthcare wasn't even
about doctors.
Speaker 2 (03:17):
Not really. Most folks relied on home remedies, maybe a
self help book, family knowledge. You called a physician for
something serious, something that wouldn't go away.
Speaker 1 (03:26):
So when you did need one, what were you faced with.
Speaker 2 (03:29):
A huge, kind of bewildering range of choices. Yeah, most
practitioners weren't mds from fancy colleges. They learned through apprenticeships,
and the quality the ideas they varied wildly. You could
get totally opposite advice from two doctors in the same town.
Speaker 1 (03:44):
And they weren't all full time doctors either.
Speaker 2 (03:46):
No, many practice part time, had other jobs and getting
paid well, unpaid bills were just part of the landscape,
very common.
Speaker 1 (03:53):
Okay. So in this mix you had the group known
as the regulars.
Speaker 2 (03:56):
Who were they, right, the regulars. These are the physicians
trying to follow classical medical theories. They formed state societies.
They were trying to embrace science aligned with what became
the AMA.
Speaker 1 (04:08):
But they weren't alone. There were lots of alternatives that
your regular oh yeah, a whole skeptrum.
Speaker 2 (04:12):
You had Tomsonians, they were big on herbal remedies, kind
of a do it yourself approach, botanics who were more
trained herbalists, hydropaths all about water cures, and then the
really big ones homeopaths using deluded remedies, surprisingly popular even
with educated folks.
Speaker 1 (04:29):
Really, homeopaths were popular with the.
Speaker 2 (04:31):
Elite, yeah they were. And then you had the eclectics.
They were kind of open to anything except harsh chemicals,
preferred gentle herbs, rest plus just countless others who weren't
really organized, eye doctors, cancer doctors, people calling themselves Indian doctors,
faith healers, bone setters, midwives, and tons of mail order
(04:52):
cures promising everything under the sun.
Speaker 1 (04:54):
So it really was a free for all. Why didn't
the regulars who thought they were the real doctors just
get laws passed to shut everyone down?
Speaker 2 (05:00):
They wanted to, right, they definitely wanted to. They called
the others dangerous, Charlatans, quacks. But here's the key thing.
They couldn't prove they were better. They couldn't prove it,
not objectively, especially for internal medicine. State legislators weren't convinced.
In fact, during epidemics in the eighteen forties fifties, the
homeopaths sometimes had.
Speaker 1 (05:21):
Better outcomes, no kidding, why was that.
Speaker 2 (05:23):
Well, the regulars were still doing a lot of harsh treatments, bleeding, purging,
strong emetics. Sometimes these treatments were arguably more dangerous than
the disease. So you couldn't just walk into the state
house and say our science is better when the results
didn't consistently back it up.
Speaker 1 (05:39):
So it wasn't just about science versus quackery. It was murkier,
much murkier.
Speaker 2 (05:45):
And the regulars, honestly, they developed this attitude that the
public was just too gullible and ignorant to see the truth.
Their belief was almost well religious. They felt the public
had to be forced by law to accept scientific medicine
for their own goods.
Speaker 1 (06:00):
That's quite an attitude, it is, and the result.
Speaker 2 (06:03):
By the time the Civil War started in eighteen sixty one,
there were basically no effective medical licensing laws anywhere in
the US. It truly was the wild West, Okay.
Speaker 1 (06:11):
So after the Civil War things start to shift. The
regular physicians they try again and West Virginia, this brand
new state born out of the war, becomes kind of
a test case right exactly.
Speaker 2 (06:22):
It's politics were still fluid, less entrenched. It presented this
unique window an opportunity for the regulars.
Speaker 1 (06:28):
And this is where the Medical Society of West Virginia,
the MSWV comes in right.
Speaker 2 (06:33):
Founded in eighteen sixty seven by a small group of
elite educated regulars led by doctor James Reeves. Reeves was
absolutely convinced about the need for formal scientific education. He
saw the MSWV as the true church of medicine. Their
goal was clear, were strict practice to those they deemed
professionally worthy, meaning formal degrees following AMA guidelines.
Speaker 1 (06:53):
But it wasn't smooth sailing even for them.
Speaker 2 (06:56):
Not at all. There were internal splits. Southern doctors, former Confederates,
felt excl luted by the Northern leadership, and membership was tiny.
Less than ten percent of the doctors in the state joined.
Why so few, well, many regulars themselves were apprentice trained.
They worried that strict licensing, demanding formal degrees would push.
Speaker 1 (07:13):
Them out to interesting so even within the regular camp
there was fear about these new standards definitely.
Speaker 2 (07:19):
But the leaders like Reeves and his key ally, doctor
George Baird. Yes, that doctor Baird. They were relentless. Baird
was a big deal Civil War veteran former mayor of Wheeling,
politically savvy. In their speeches, they'd rail against quackery and
medical sinners, very strong language.
Speaker 1 (07:36):
But did they ever actually show evidence, like specific stories
of patients being harmed by these other practitioners.
Speaker 2 (07:42):
That's the really interesting part. No, not really. Their arguments
were based on conviction, on the belief in science, almost
like a faith. They didn't present case studies of harm
from irregulars. They just asserted that their way was the
only right.
Speaker 1 (07:54):
Way, and they still believe the public needed to be forced.
Speaker 2 (07:57):
Yes, Their view was the public just didn't get it,
couldn't appreciate science, and needed the law to guide them
for their own good. You know.
Speaker 1 (08:04):
So by the late eighteen seventies they decide persuasion isn't working.
Time for Plan B exactly.
Speaker 2 (08:11):
They realized they need the state's power, so they pivot.
They start pushing for a state board of Health.
Speaker 1 (08:16):
Ah, the public health angle smart.
Speaker 2 (08:19):
Very smart. They used the fear of epidemics, something everyone
could understand as a stalking horse a cover for their
real goal, licensing. They knew anti abortion bills, which the
AMA also pushed, hadn't worked for getting licensing clauses passed.
Public sanitation was a better bet.
Speaker 1 (08:37):
And doctor Baird, the well connected one he leads this charge.
Speaker 2 (08:40):
Yes, he uses his political skills, his business connections railroads
were big, and his general popularity. Remember he often didn't
bill poor patients, which made him well liked. He gets
support from key figures like James Ferguson, a major corporate
lawyer and Democratic Party boss.
Speaker 1 (08:56):
Why would a corporate lawyer care about medical licensing?
Speaker 2 (08:59):
Ferguson's saw parallels. He believed in consolidation at the top,
whether in industry or professions. Just like big corporations brought order,
scientifictly trained doctors should bring order to medicine. It fit his.
Speaker 1 (09:10):
Worldview, So this alliance works.
Speaker 2 (09:12):
It does. In eighteen eighty one, the Board of Health
Act passes. Reeves wrote the bill. Ferguson helped push it through.
There was opposition, mind you, anti monopoly democrats representing farmers
and laborers saw it for what it was, an attempt
by the allopaths the regulars to create a monopoly.
Speaker 1 (09:29):
But the key part got in the part about who
could be on the board.
Speaker 2 (09:33):
Absolutely crucial. The law stated all board members had to
be graduates of reputable medical colleges with twelve years experience.
That effectively locked out everyone else.
Speaker 1 (09:43):
And the governor appoints the board.
Speaker 2 (09:44):
Governor Jackson A. Reeve's ally appoints only staunch regulars, Reeves himself,
Andrew Barbie, who fought for it in the Senate, all
Ama alliganed guys Reeves even bosaid all members belonged to
the true Church in medicine. No subtlety there.
Speaker 1 (09:58):
Okay, So the board is in play, stacked with regulars.
What do they do first?
Speaker 2 (10:02):
They immediately start setting precedents. They hold exams for some
apprentice trained regulars, carefully handpicked ones, including George Garrison, Barrett's protege.
He passes, gets his license, Remember that detail.
Speaker 1 (10:13):
Uh huh. But things get tricky when others try to
get licensed, like the Dent family.
Speaker 2 (10:17):
Right, this is where it gets really contentious. First, Arthur Dent,
he was actually an MSWV member, but a bit of
a radical thinker. He questioned aggressive treatments, believe more of
the body's natural healing power. He didn't have a degree
or ten years practice, so he failed the board's exam.
Speaker 1 (10:34):
So what did he do?
Speaker 2 (10:35):
He quickly got an MD from a place called Columbus
Medical College, which apparently waived residency for him. Controversial. The
board was furious. They declared the college disreputable based on
new strict criteria they just drafted basically AMA standards, two
full years of study, labs, et cetera.
Speaker 1 (10:53):
And they rejected his degree.
Speaker 2 (10:55):
Flat out rejected it. Arthur eventually just gave up and
left West Virginia.
Speaker 1 (10:58):
Okay. Then there was his cousin, Frank Dent.
Speaker 2 (11:01):
Frank Dent, also apprentice trained from a family of doctors.
His own father had been MSWV president, actually arguing for
a more inclusive approach. Frank initially got a license under
a ten year grandfather clause, but Reeves suspected fraud. Thought
the clause was meant for Frank's elderly bedridden grandfather, not
Frank himself.
Speaker 1 (11:18):
So Reeves is suspicious. What does Frank do?
Speaker 2 (11:21):
Frank goes and gets an MD from an eclectic medical college,
the American Medical Eclectic College or AME. The board unanimously
rejects that too, calls amec not reputable, and they threatened
to prosecute Frank criminally if he keeps practicing.
Speaker 1 (11:35):
Wow, so Reeves is really playing hardball now, Oh yeah.
Speaker 2 (11:38):
He's board secretary, he's MSW president. He basically boasts about it, saying,
only through this kind of very great authority can they
force reform. He's drawing a line in the sand.
Speaker 1 (11:49):
So Frank Dent gets indicted for practicing without the board's approval.
And his lawyer is his cousin, his.
Speaker 2 (11:55):
Cousin, Marmaduke Dent. And Marmaduke is not just any lawyer.
He's a rising star in the anti miniomply wing of
the Democratic Party, a future West Virginia Supreme Court justice
known for defending the poor. This is setting up for
a major legal fight.
Speaker 1 (12:08):
What was Marmaduke's argument in court?
Speaker 2 (12:11):
He had heard. He argued the law was unconstitutional, a
sham designed purely to create a monopoly for the regulars.
He called it an expost facto law punishing Frank for
practicing when it had been legal. He argued it violated
inalienable rights.
Speaker 1 (12:24):
And he brought up this idea of medical practice as property.
Speaker 2 (12:27):
Yes, that was key, He argued, practicing medicine was a
form of property and the state couldn't just take it
away without due process. He cited older cases involving lawyers
who lost their right to practice, and he didn't pull punches.
He accused Reeves on the Board of selfishness, arrogance, and egotism.
Said their goal was to shut out competition, raise their fees,
(12:49):
increase their wealth, and give themselves political prominence. Strong stuff.
Speaker 1 (12:54):
How did the West Virginia Supreme Court respond to that?
Speaker 2 (12:57):
They sided with the state in eighteen eighty four. They
upheld the law. They bought the argument that this was
a valid use of the state's police power to protect
public health.
Speaker 1 (13:06):
Frank Gent lost, so the Board feels vindicated.
Speaker 2 (13:09):
Absolutely. Reeves and the Board push even harder. They grant
fewer licenses based on exams, focusing almost entirely on graduates
from reputable, meaning AMA approved schools. They're tightening the screws.
Speaker 1 (13:22):
And then comes that weird twist with George Garrison getting
appointed to the board.
Speaker 2 (13:25):
Isn't that something? Governor Wilson appoints Garrison to the board
even though Garrison himself got his MD in only seven
months from a school usually required.
Speaker 1 (13:33):
Two years, so his credentials weren't exactly stellar by the
board's own new standards.
Speaker 2 (13:37):
Not at all, and the MSWV saw it as a
political job, highlighting the Board's earlier inconsistency. Remember, Garrison passed
that very trivial exam back in eighty one, while the
Dents were rejected.
Speaker 1 (13:50):
So as the politics involved, did the courts ever waiver
any second thoughts?
Speaker 2 (13:54):
Nope. In eighteen eighty eight, the West Virginia Supreme Court
upheld the Board again in a case called State v. Ragland.
They admitted the law was maybe crudely drawn, but they
weren't going.
Speaker 1 (14:03):
To interfere, which leads us to the biggest stage of
all Frank Dent appeals again.
Speaker 2 (14:08):
He takes it all the way to the United States
Supreme Court Dent v. West Virginia. This is the ultimate
showdown eighteen eighty nine. The fate of medical licensing in
America really hangs in the balance.
Speaker 1 (14:19):
Marmaduke makes his case again property rights, due process he.
Speaker 2 (14:22):
Does, but the Supreme Court unanimously sides with West Virginia.
Justice Stephen Field wrote the opinion unanimous.
Speaker 1 (14:30):
Wow, what was their reasoning? This seemed like a big
shift from protecting economic rights.
Speaker 2 (14:34):
It was, and that's why it was kind of confusing
to legal folks at the time. Justice Field essentially carved
out an exception for medicine. He said, medicine isn't like
ordinary advocations. It's subtle and mysterious, and the public is
vulnerable to ignorance and incapacity. Therefore, the state needs to
protect them. He basically said, the state can make a
(14:55):
policy wager. It can bet on one approach, in this case,
scientific educated physicians, even if it means destroying the property
the practices of existing doctors who don't neet the new standard,
and it can do this without the kind of due
process you might expect for other property.
Speaker 1 (15:11):
So the state gets to pick winners, essentially in the
name of public health.
Speaker 2 (15:15):
That's the core of it. It gave states the constitutional
greenlight to say, we believe this type of preparation leads
to better outcomes, so we're limiting practice to those who
have it, even without definitive proof of better outcomes at
the time, and even if it harmed existing practitioners.
Speaker 1 (15:31):
This sounds like the birth certificate for the modern medical license.
What did it actually create, this preparation only license.
Speaker 2 (15:37):
It created a system where doctors could use the state's
power to control entry into the profession who gets to
be a doctor based solely on their initial training and credentials.
But and this is crucial, it didn't come with scrings
attached regarding ongoing performance or public accountability, meaning meaning no
state mandated fee gaps, no requirement to serve under ser areas,
(16:01):
and critically no requirement for continuing education or any system
to monitor how well doctors actually practiced after they got
the license.
Speaker 1 (16:09):
So the focus was all on getting the license, not
on what happened afterwards. If the goal was protecting the public,
that seems incomplete.
Speaker 2 (16:16):
Massively incomplete, and you could argue it ironically helps hide
problems for a long time. Think about it. If the
license is mainly about initial preparation, there's less focus on
ongoing confidence. It took decades, really, until reports like the
Institute of Medicines in nineteen ninety nine to highlight the
huge numbers of preventable medical errors happening within the licensed system.
Speaker 1 (16:36):
That report estimated what almost one hundred thousand deaths a
year from hospital mistakes, up.
Speaker 2 (16:40):
To ninety eight thousand deaths. Yes, and licenses were almost
never revoked for poor care, mostly just for criminal acts
or maybe substance abuse. The system wasn't built to track
or address routine clinical.
Speaker 1 (16:53):
Performance, so didn't force states to only license AMA style doctors,
but it allowed it exactly.
Speaker 2 (17:00):
It opened the door constitutionally, and predictably, the AMA regulars
walked through it. They came to dominate the state licensing boards,
and from that position they influenced everything. Medical school curricula, internships,
specialty certifications, all largely on their terms.
Speaker 1 (17:14):
Which leads to consolidation inexorably.
Speaker 2 (17:17):
In West Virginia. The final step came in nineteen twenty one,
a new law required all applicants to have degrees from
schools specifically approved by the AMA. Game over for the alternatives.
Speaker 1 (17:26):
Really, and that Struccher born in these battles is basically
the foundation of the healthcare system we have now, the
good and perhaps some of the bad.
Speaker 2 (17:33):
Absolutely the incredible advances, the high standards of training, but
also some of the issues around access, cost and maybe
insufficient focus on ongoing quality assurance. It all has roots
back here.
Speaker 1 (17:44):
Okay, before we wrap up, let's quickly go back to
where we started Wheeling eighteen ninety one. What happened to
doctor Garrison after he shot doctor Baird.
Speaker 2 (17:52):
The Great Doctor's Murder case, as the papers called it,
dragged on for two years, multiple trials. What was the
defense provocation? Garrison's lawyers argued that Baird had relentlessly taunted
and threatened him, pushing him past his breaking point. Remember
Baird was Garrison's former mentor. Then they fell out, possibly
linked to that board appointment controversy. After one mistrial and
(18:15):
one hung jury, Garrison was finally convicted, but only of
involuntary manslaughter.
Speaker 1 (18:20):
Involuntary after shooting him twice.
Speaker 2 (18:23):
Seems light, doesn't it. He was sentenced to on these
seven more months in jail he'd already served fifteen awaiting
trial and a two hundred and fifty dollars fine.
Speaker 1 (18:30):
Wow, a rather small PostScript to such a huge historical shift.
Speaker 2 (18:34):
A very small, sad personal consequence of this much larger
battle over who gets to control medicine.
Speaker 1 (18:40):
So the next time you find yourself in a doctor's office,
maybe take a second to think about the history behind
that license on the wall. It wasn't a simple linear
path to scientific truth. It was a fight about power,
about money, about different ideas of healing, and ultimately about
the state making that policy wager.
Speaker 2 (18:58):
And that Dent decision, It really cemented the state's power
to choose one model, the academically defined preparation focus model,
even if it meant pushing other approaches aside and creating
a system where performance wasn't tracked nearly as closely as preparation.
Speaker 1 (19:16):
Which leaves us with a final thought to chew on.
In our system today, built on Dent and everything that followed,
how much do we still emphasize that initial preparation, the degree,
the boards, the license, compared to tracking and ensuring ongoing
real world performance and the incredibly complex field of medicine.
Speaker 2 (19:32):
Yeah, where is that balance now? And what are the
potential costs to you the patient? If that balance isn't
quite right? Something to think about.
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