Since the early 20th century, state licensing boards have only granted licenses to graduates of medical schools accredited by the American Medical Association’s (AMA) Council on Medical Education. As a result, the number of medical schools began to decline, from a peak of 162 in 1906 to 131 in 1910.

The AMA originally denied membership to African American physicians and, until the 1960s, allowed state chapters to exclude Black physicians. African American medical societies were founded as an alternative. In 1895 these societies banded together to form an alternative to the AMA, the National Medical Association (NMA).

Abraham Flexner’s 1910 report, “Medical Education in the United States and Canada,” commissioned by the AMA and the Carnegie Foundation, established criteria to standardize and improve medical education in the United States and Canada. The AMA Council on Medical Education endorsed and adopted the report’s recommendations, transforming medical education into what exists today.

The Flexner report forced the closure of many more medical schools, reducing the physician supply in the process. By 1923 the number of accredited medical schools had dropped to 66. Five of the seven Black medical schools that existed at the time of the report were closed by 1923. Flexner also recommended 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.

States also require at least one year of postgraduate training (internship) for a license to practice medicine. But Black graduates were often excluded from internships and from hospital privileges at most institutions, which impeded the delivery of health care, especially to patients in the Deep South.

In 2008 the AMA issued a formal apology to the nation’s African American physicians for its decades of racial discrimination. Through her scholarship, Harriet A. Washington, a writing fellow in Bioethics at Harvard Medical School, was largely responsible for making that happen. Washington, along with Marshala R. Lee and Jeffrey A. Miron, will discuss how licensing can become a tool to affect racist ends.