BY MIKE MAGEE

Health entrepreneurs today tend to give themselves very high grades, and seem surprised when their creations fall short of expectations due to a disconnect with funders or regulators with legal authority. But Medicine isn’t fair, and genius is not that common.

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 and could well serve as a yardstick for medical imagineers today. 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 1966 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, author of American Medicine in Transition, 1830-1910, and former editor of Caduceus 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 sets 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, 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.”

Mike Magee M.D. is a Medical Historian and author of CODE BLUE: Inside the Medical Industrial Complex.