The best way to understand the contemporary politics of allopathic medicine in California is to peek behind the curtain of our state’s modern-day Medical Practice Act to its original 1876 “Healing Arts Act” and California’s first attempt to legally define and regulate the use of the word “doctor”.
So here is a brief historical account of licensing for medical doctors, beginning in California in 1876. It helps identify how state medical licensing laws, in conjunction with the national agenda of organized medicine, impact the professional practice of midwifery and other non-allopathic healthcare options.
California gained statehood in 1850, but the first legislative secession was not held until 1876. A progenitor medical practice act passed that year mandated state licensure for doctors under a legislative heading known as “The Healing Arts”.
The purpose of these new laws was to assure competent practice by those who called themselves doctors. Licensing laws restricted those who could legally use the title“doctor” to medical practitioners who “qualified”. Statues defined this as the ability to demonstrate knowledge of the biological sciences as they pertain to the practice of medicine (i.e. pass a written and oral state board), and the ability to apply medical knowledge and clinical skills by successfully graduating from a medical school in their particular discipline.
The original practice of medicine as a “Healing Art” included homeopathy, naturopathy, osteopathy, allopathic, chiropody (foot doctor) and a category called “eclectic”. This described physicians who used an eclectic blend of ‘natural’ and allopathic of methods. Doctors who did not use any allopathic drugs when treating patients were licensed as “drugless practitioners”.
The original ideas conveyed by the words ‘medicine’ and ‘medical’ did not refer to the use of drugs or surgery or any other specific modality, but to the general activity of a trained person treating the ill and injured by a variety of methods. The word ‘medical’ comes from a Latin root that means: “to heal or cure”. The ancient idea of ‘physician’ originally described someone who provided physical services (i.e. not mental, spiritual or religious) in the field of bodily health. This can still be seen in our use of the word “medic”.
As the art and science of restoring or preserving health, the essential core of medical practice focused on the ‘doctor-patient relationship’ — a mutually-beneficial ‘therapeutic relationship” between the patient and the practitioner. This ‘healing relationship’ was irrespective of the particular method of treatment used by the physician. Based on this historic definition of medicine as a Healing Art, the Medical Board issued licenses in 5 specific categories representing each discipline. The holder of such a certificate was licensed as a ‘physical healer’ and fully authorized as an MD to enter into therapeutic relationships in California.
This all changed drastically in the wake of the AMA-sponsored 1910 Flexner Report (see “AMA, NMA and the Flexner Report of 1910” prepared by Dr. Olakanmi, MD). Publication of this report forced the closure of non-conforming medical schools as defined by the AMA, which included all medical schools that taught any kind of non-allopathic method of treatment. An extremely high percentage of schools that accepted women students, immigrants and non-whites were also closed, citing their inability to live up to the “high standards” set by the AMA’s Council on Medical Education for allopathic medical education.
The mania to purge the medical profession of ‘irregular doctors’ also fueled an on-going national campaign to eliminate the non-allopathic practice of medicine in general. By 1911, the California medical practice act no longer licensed the Healing Arts of homeopathy, naturopathy or ‘eclectic’ physicians. Those already licensed in such disciplines were permitted to practice, but no longer had a role in governing the medical profession.
Until 1910, the California Board of Medical Examiners was composed of 6 non-allopathic and 5 allopathic doctors recommended by the professional organizations of the various disciplines. After the 1911 amendment to the medical practice act, the only discipline allowed sit on the Board’s governing panel were 12 allopathic doctors (same as today). The practice of medicine was no longer functionally defined as a ‘healing art’, as the general title of ‘medical doctor’ and the word ‘physician’ were now restricted to those who treated with drugs, ionizing radiation and surgery. Non-allopathic disciplines were denigrated as quackery and its practitioners labeled charlatans; many were prosecuted for illegally practicing medicine.
The legacy practice of midwifery becomes the unloved and ugly step-sister of the medical profession
Not long after the publication of the Flexner Report the legacy practice of midwifery as an honorable profession and respected public service began a long slow slide into its current role as the unloved and ugly step-sister of the medical profession. As a non-medical (i.e. non-allopathic) discipline, the legal tension between allopathic medicine and midwives remains unchanged. Community-based midwifery as a ‘low medical-intervention’ model continues to be contrasted with obstetrics’ ‘high medical-intervention’ model and defined as substandard. According to MDs, midwifery is both aberrant and dangerous.
It should be noted that that AB 1375, which authorized the first midwifery licensing law in 1917, never referred to it as a licensing act. All other state-licensed health professions – doctors, nurses, dentists, even state-certified nursing assistants – are entitled to the exclusive use of their professional title after their name (MD, RN, DDS, CNA, etc) and exclusive access to a unique scope of practice—all except for the midwifery profession.
The 1917 midwifery provision and subsequent licensing acts for both CNMs and LMs midwives do NOT entitle midwives to an exclusive scope of practice as midwives, that is, providing normal maternity care for essentially healthy childbearing women. While we have a professional title (CNM, LM), we do not have exclusive rights to provide the services within our official scope of practice. MDs however have always enjoyed an unlimited scope of practice that legally encompasses all aspects of the ‘Healing Arts’, including maternity care to healthy women.
As a point of contrast, Article 24 states the purpose of the original midwifery provision as “relating to the practice of midwifery, providing the methods of citing said act, and .. penalties for the violation thereof.” As plainly explained, AB 1375 gave the medical profession legal control over the practice of midwifery, with rights to ‘cite said act’ and impose ‘penalties’ on its practitioners. The biggest issue was boy toys vs. girl toys — keeping the girls from playing with the boy’s toys.
AB 1375 legally prohibited midwives from using private formulary preparations, that is, making up their own medicinal ‘products’ or drugs (a common practice for MDs). It also prohibited the use of surgical instruments except for sterile scissors to cut the umbilical cord, or anything else remotely associated with the practice of allopathic medicine. Strict adherence to non-medical policies even forbid midwives from manually removing a retained placenta when a new mother was hemorrhaging, even if necessary to save her life. Threatening to revoke a midwife’s license would assure compliance; if that didn’t work, midwives would be criminally prosecuted for practicing medicine without a license.
AB 1375 simply declared that: The holder of a license to practice midwifery is not authored to practice medicine or surgery. This 1917 phrase was later inserted by medical lobbyists into the CNM licensing laws in 1974 and the LMPA in 1993.
Nonetheless, I think midwives got the ‘last laugh’, since we don’t want to practice medicine or compete with the obstetrical profession. We like our ‘girl toys’, such as patience with nature, full-time presence of the midwife during active labor and right use of gravity during the pushing phase.
Some of us think the principles of physiological management and associated skills help laboring women to get the baby out even better than many of the ‘boy toys’ that obstetricians are so fond of.
I’m one of those people.