America is taking a long-overdue look at the racism inherent in the criminal justice system. But racism also infects occupational licensing laws, and medical licensing laws are no exception.

The American Medical Association was founded in 1847, during a period of “free trade in medicine,” with the mission of promoting medical licensing laws. The AMA House of Delegates voted in 1868 to allow women physicians to become members and left it up to state chapters to decide whether to admit black physicians, stipulating “local medical societies should have a right to enact segregationist or sexist admission standards without interference from the national society.” In the District of Columbia, the National Medical Society, an integrated medical society made up of physicians from Howard University and the Freedman’s Hospital, was refused recognition by the AMA.

Writing in the AMA Journal of Ethics, bioethicist Robert B. Baker, PhD states:

The AMA’s policy of tolerating racial exclusion was pivotal in creating a two-tier system of medicine in the American South and border states—racially divided, separate, and unequal. Within a decade African American medical societies were founded as an alternative. In 1895 these societies banded together to form an African American alternative to the AMA, the National Medical Association (NMA).

This remained the policy of the AMA until the 1960s.

By the late 19^th century, largely through the work of its state chapters, the AMA began succeeding in its quest to get states to license medical doctors. The state chapters wielded great influence over who served on the licensing boards and the regulations that were enacted.

Medical education was very heterogenous at the turn of the 20^th century. There were variations in years of schooling, clinical and research experience, and entrance requirements. Many medical schools didn’t require applicants to have an undergraduate degree. The medical association-dominated state licensing boards would only grant licenses to graduates of medical schools if they were accredited by the American Medical Association’s Council on Medical Education. In The Social Transformation of American Medicine, Paul Starr notes the number of medical schools began to decline, from a peak of 162 in 1906 to 131 in 1910.

In 1910, educator Abraham Flexner issued a report on Medical Education in the United States and Canada, which came to be known as the Flexner Report. It was commissioned by the AMA and the Carnegie Foundation. The report established criteria to standardize and improve medical education in the U.S. and Canada. Its recommendations were endorsed and adopted by the AMA Council on Medical Education and transformed medical education into what exists today.

This forced the closure of many more medical schools and reduced the physician supply in the process. By 1923 the number of accredited medical schools dropped to 66. Five of the seven black medical schools that existed at the time of the Flexner Report were closed by 1923. Only Howard University School of Medicine in Washington, D.C. and Meharry Medical College in Nashville, TN remained.

Journalist Elizabeth Hlavinka writes:

In his report, Flexner wrote that African-American physicians should be trained in “hygiene rather than surgery” and should primarily serve as “sanitarians,” whose purpose was “protecting whites” from common diseases like tuberculosis.

The schools that closed, including Flint in New Orleans, Leonard in Raleigh, and Knoxville in Memphis, were “wasting small sums annually and sending out undisciplined men, whose lack of real training is covered up by the imposing MD degree,” Flexner wrote.

Although some standardization of medical education was necessary, Flexner’s report gravely diminished the number of African Americans who could have become physicians, said Earl H. Harley, MD, of Georgetown University, who has written about the forgotten history of defunct Black medical schools.

Paul Starr states:

Blacks also faced outright exclusion from internships and from hospital privileges at all but a few institutions. The scarcity of opportunities for training and practice had material impact. In 1930 only one of every 3,000 black Americans was a doctor, and in the Deep South, the situation was even worse—in Mississippi, blacks had one doctor for every 14,634 persons.

Women were also impacted by medical licensing laws in the wake of the Flexner Report. Starr explains:

As places in medical school became more scarce, schools that previously had liberal policies toward women increasingly excluded them. Administrators justified outright discrimination against qualified women candidates on the grounds that they would not continue to practice after marriage. For the next half of the century after 1910, except for wartime, the schools maintained quotas limiting women to about 5 percent of medical school admissions.

Richard Menger and I recently wrote about how the coronavirus pandemic provides a stark lesson in how medical licensing laws obstruct the free flow of health care practitioners to areas in need, reduce access to health care, and have little to no effect on the quality of health care. When compiling a list of the deleterious effects of medical licensing laws, it’s important that the list includes their racist elements.