ACP American College of Physicians - Internal Medicine - Doctors for Adults

The American College of Physicians: The First 75 Years

Bernice R. Lemley, MEd

Annals of Internal Medicine, 1 June 1990. 112:872-878.

The founding and progress of the American College of Physicians (ACP) have been variously interpreted in three published histories and in other documents (1-5). A student of its 75-year meteoric growth might well conclude that Shakespeare's "seven ages of man" have their parallel in the eras of institutions: The College has progressed through four of seven (ACP Chronology). How its recent course will determine its future years must remain for historians of a later time.

Some of the four eras have had initiating events in earlier ones and culminations in the next, thus overlapping. Each era is distinguished by the great energy that was applied by the College to its dominant theme in response to demands of the times:

1. The age of identity, 1915 to 1926, in which the College worked to define its being.

2. The age of knowledge, 1927 to 1967, in which the College focused on defining and contributing to the body of knowledge that makes up internal medicine.

3. The age of collegial cooperation, 1960 to 1977, in which the College asserted leadership in representing internal medicine among medical societies.

4. The age of social responsibility, 1971 to 1990, in which the College came to grips with some hard truths about the practice of medicine: that the healing of the patient is deeply rooted in the healing of the social order; that the right of the medical profession alone to interpret the Hippocratic Oath is being challenged in the public sector; and that the 20th Century slogan, "If it ain't broke, don't fix it," offers little comfort in the face of social derangements not cured by legislation or conglomerate planning to solve health crises of entire populations (6-9).

The Age of Identity

The College began as the concept of one man. Heinrich Stern was German by birth and in his orientation to medical education. His perspectives on medical practice were profoundly influenced during a conference in England in 1913 by his view of the Royal College of Physicians of London. He returned determined to establish a similar society in the United States. On 8 January 1915, the American Congress of Internal Medicine was incorporated for "the purposes of facilitating scientific intercourse among physicians interested in internal medicine...." The Congress had no particular standards for membership other than interest in its purposes. Its only activity was to be an annual clinical congress. The Congress elected a governing Council from among "those recognized for their eminence in medicine. "

On 11 May 1915, the Council filed the Articles of Incorporation of the American College of Physicians in New York State. With a certificate of incorporation filed in Delaware on 19 May, the College first met (10) on 25 June 1915 to elect officers, approve its bylaws, and officially elect the Council as its first Fellows (Early photo of Fellows). Heinrich Stern died suddenly in 1918, leaving the dichotomies implicit in the existence of both a Congress and a College for his colleagues to resolve.

The first decade was an amorphous period of constantly shifting organizational changes and vacillation between inclusive and exclusive models of membership. From its beginning, the College diverged from its founder's view of the Royal College of Physicians as its model. The Royal College, granted its charter as a guild in 1522, is not only the standard-bearer of English nonsurgical medicine but the direct arbiter of its practice. The American College of Physicians, incorporated as an educational institution, held no similar judicial powers, eventually delegating such powers for a certifying board, in a pattern also followed by other U.S. specialty societies.

From its inception, the Royal College maintained elections to limited Fellowship. When the ACP was founded in 1915, the 400-year-old Royal College (11) had 355 Fellows and 512 Members and licensed in that year 13,106 new physicians. Within 5 years of its founding, the ACP had elected 518 Fellows. The Board of Regents (organized in 1922) debated growth and standards until 1926, when it devised a plan to admit as Associates of the College members of the Congress unqualified for Fellowship. The traditions of the Royal College weighed heavily on membership questions until 1969-70. Affirming the mission statement that the ACP existed to educate, the Board then revised the bylaws to reclass the large group of indefinite-term Associates to permanent Members and to admit physicians-in-training as Associates. Latin American scholars, admitted as Affiliates since 1963, were offered full Member and Fellow status in 1981, when Affiliate membership in the College was abolished. A membership of over 68,000 in 1990 reflects the College's divergence from the concept of a select guild of eminent physicians.

Initially, the ACP muddled through a democratic style of governance, with an enlarging Council determining policy and a small Board of Directors acting as trustees. Quickly finding this structure unmanageable, it reorganized in 1922, with the Board of Regents as its governing body and the Board of Governors representing the membership in their respective regions. State chapters were not organized until 1974. Regional meetings began spontaneously in 1930, when Fellows began to meet at luncheons during state medical society meetings, North Carolina leading the way.

Governance was reorganized again in 1926-27. President Alfred Stengel (1925-27) of Philadelphia pressed to recruit academic physicians to the College, with the support of Charles F. Martin of Montreal (Fellow, 1924; President, 1928-1929), who proposed many academic physicians. They were immediately elected and soon assumed leadership, giving the College a strong academic base.

Academic undergirding was further aided by the moving of the College office to Philadelphia (Headquarters Buildings, top right and left), near the University of Pennsylvania, setting the stage for educational initiatives. The next decade took its impetus from some events in 1927. Life memberships and the hiring of a full-time Executive Secretary, Mr. Edward R. Loveland, prepared the College to weather the national economic depression and emerge with a sound financial base. In 1927, the College began publishing its own journal, Annals of Internal Medicine, and the Board of Governors began to survey available postgraduate courses in internal medicine in the United States and Canada.

The Age of Knowledge

Establishment of the American Board of Internal Medicine (ABIM) in 1936 with support from the College identified the internist as a physician with a certifiable body of knowledge. Board recognition and certification required new educational initiatives. In 1938, the College began to sponsor postgraduate courses in U.S. and Canadian medical schools. The onset of World War II fostered scientific sessions at formal regional meetings and expanded postgraduate courses as Governors mobilized training for military medical personnel. In the postwar years, the biomedical sciences exploded within American medical education. Federal funds for research changed both the substance and the modes of acquiring and disseminating medical knowledge. Research spawned numerous special branches of knowledge; new subspecialties clamored for board recognition and certification. The definition of an internist, a perennial topic of presidential addresses and publications, was intensely debated in policy sessions on ACP membership.

For the practicing internist, continuing education became a race to keep abreast of rapidly growing new medical knowledge and technology. In 1956, a new committee assumed as its sole responsibility the ACP Fellowships and Scholarships program. The Annals of Internal Medicine was now well established, with a circulation of 28,000 in 1963; by 1970, its worldwide circulation had nearly doubled to 42,000.

On the eve of the College's 50th anniversary, intensely debated issues of quality of care and recertification forced the Board of Regents to consider the intensity and scope of knowledge change to reassess its methods of supporting continuing education for the practicing internist. The result was a precedent-setting educational initiative, the Medical Knowledge Self-Assessment Program (MKSAP). The brain child of Hugh R. Butt (President, 1971-72) and of the Education Committee he chaired, it was produced with the expert assistance of the National Board of Medical Examiners. First published in 1967 as a modest effort to help the physician prepare for recertification, its success exceeded all expectations. Now in its eighth edition, with translations into Japanese in 1971, French in 1979, and Spanish in 1990, it is a continuing education model that has been adopted by many medical and nonmedical professional societies.

The Age of Collegial Cooperation

Incipient regular involvement in intersocietal affairs was evident during World War II, when the entire medical profession united to train military physicians and met in committees to shape postwar medical planning. The College joined in intersocietal sponsorship of the Joint Commission on Accreditation of Hospitals (JCAH), which incorporated in 1951. This sponsorship typified a crucial change in the nature of the College's affairs: In the previous era, its energies were focused in the ABIM, physician training, and certification. Sponsorship of the JCAH added to the College's purview a long-term commitment to upgrade the context in which training and practice occur through the accreditation of programs and facilities.

Participation in the intersocietal Conference Committee on Graduate Medical Training (1939) was interrupted by World War II. In 1953, the project was reactivated as the Residency Review Committee for Internal Medicine. The Commission on Professional and Hospital Activities, founded in 1955, expanded the College's sponsoring role to include quality of care review. After 1960, intersocietal representation grew rapidly. In 1956, representatives to 15 groups appeared on the College's liaison list. What the College had shunned in its first decade, when it was difficult to control the Secretary-General's enthusiasm for intersocietal involvement, was now defined as the norm and mandate for the new physician Executive Director, Edward C. Rosenow, Jr., in 1960.

The era was epitomized by the formation of the Tri-College Council (1965), later renamed the Council of Medical Specialty Societies (1968), to provide the specialties with a forum of their own. Intersociety links reached their peak in 1976, when representatives were appointed to no less than 31 intersocietal groups, encompassing physician education, certification, hospital accreditation, allied health professions, the "wars" on chronic diseases, nosology and epidemiology, rehabilitation, international medical education, laboratory medicine and research, audiovisual technology, manpower, and specialization.

The Age of Social Responsibility

By 1970, governmental roles in funding education and research and underwriting health care were so pervasive that a programmatic shift to public affairs was inevitable. Now in the mainstream of intersocietal defining of medical policy, the College focused its agenda on marked changes in health care delivery and financing. This evolution was determined in part by an event of 1971: Efforts toward an amalgamation of the ACP and the American Society of Internal Medicine (ASIM) concluded without success.

Re-evaluation followed. The Medical Practice Committee was formed (1972) to review and articulate the College's role in interpreting health policy issues to its own membership. The Toronto conference of Regents and Governors (1974) reassessed the processes of national policy-making and their relation to grassroots realities; through the process described below, chapters were formed, New Mexico and Illinois leading the way in 1974; Governors' Conferences, first held in 1968, began to include forums on major health policy issues, with eminent medical and nonmedical experts sharing the rostrum.

In 1974, the Board of Regents, searching for means to represent its membership and the specialty in health policy issues while preserving intersocietal cooperation, approved the formation of the Federated Council for Internal Medicine, which might be able to "speak with one voice" for internal medicine.

Chapter formation had begun in April 1971 when the Board of Governors adopted a far-reaching resolution (later approved by the Board of Regents) that the Masters, Fellows, and Members within College jurisdictional areas may constitute a Chapter, the presiding officer of which would be the Governor. A year later, ACP President William A. Sodeman appointed an ad hoc committee to study the organization of uniform Chapters in all parts of the country. In April 1973, the Board of Regents declared that the formation of local Chapters should be encouraged, with uniform bylaws and articles of incorporation. At the direction of the Regents, the Executive Vice President, Edward C. Rosenow, Jr., drew up the proposed documents and sent copies to the Governors. Chapter formation, at first, was purely voluntary. In 1976, the Executive Vice President was able to report that 14 Chapters had been incorporated. Between 1976 and mid-1986, 38 additional regions were incorporated as Chapters. The Alaska region became the 52nd and final Chapter in April 1990.

In 1977, Edward C. Rosenow, Jr., retired as Executive Vice President; Robert H. Moser was appointed to succeed him; James A. Clifton was elected President. Reaction came to a head and yielded to initiatives: A Task Force on Structure and Function was appointed, ending in 1981-82 with the most sweeping organizational changes since the period from 1926 to 1928. Attention to health and public policy was introduced in 1978 through establishment of a new staff department with an ACP presence in Washington (1981) and a policy committee (1982).

A critical look at management revealed that the College was ill prepared to shed reaction in favor of initiative. Major changes in financial management, staff development, and operations resources followed. The staff doubled in 5 years; space was leased in the Federal Reserve Bank in 1984, and a committee began the search for a new headquarters. In March 1989, the now historic Eisenlohr Mansion complex, home to the College for 63 years, was sold (Headquarters Buildings, bottom left). In the newly built headquarters on Sixth Street at Race, the President's office overlooks 200-year-old Independence Hall (Headquarters Buildings, bottom right).

Addition of health and public policy to the College's mission statement broadened the base of participation in policy formation. Chapter formation was concluded in all states in the spring of 1990; legislative retreats were held; committees on major health policy issues were established. Committee membership, traditionally drawn from the Board of Regents and the Board of Governors, was increasingly drawn from all classes of the membership; a Council of Subspecialty Societies (1977) and a Council of Medical Societies (1979), were formed and were represented on the Board of Regents.

New modes of information flow to the membership and to the public were employed. Health and public policy issues were editorial priorities in the new Forum on Medicine, which replaced the Bulletin of The ACP in 1978 and was succeeded by ACP Observer in 1981. Adopted policy statements were published and widely disseminated.

Patient education efforts began in earnest with Healthscope, videotapes on disease-specific problems and preventive medicine, produced in collaboration with The Upjohn Company and the ACP's Health Library, a patient education newsletter. In medical education, agreements were concluded in 1989 with Lifetime Medical Television for regular ACP programming. A Medical Informatics Committee (1985) was charged to educate leadership and members in state-of-the-art informatics technologies and applications.

Investigative studies were sponsored. A major continuing series of manpower studies, sponsored by the Federated Council on Internal Medicine with foundation funding, began publishing (12) its findings in the Annals in 1979. In 1979, the College helped to support the formation of the Society for Research and Education in Primary Care Internal Medicine (renamed the Society for General Internal Medicine in 1987). The secretariats for this society and the Association of Program Directors in Internal Medicine are now housed in the College's Washington Office.

The Clinical Efficacy Assessment Project (CEAP) and, later, the Clinical Privileges Project were to the "Age of Social Responsibility" what MKSAP was to the "Age of Knowledge." Begun with a three-year grant in 1981 from the John A. Hartford Foundation, CEAP became a fully funded activity of the College in 1984. Today it is recognized as the premier technology assessment activity in the private sector" (13). Since 1981, guidelines from the projects have been regularly published in the Annals.

The subjects of College policy statements have shown marked changes since 1960. Among the 42 statements issued from 1960 to 1975 (3) educational standards predominated: 50% related to training programs, certification, and facilities accreditation for training; 30% concerned health care delivery and medical practice issues; 9% delineated issues of disease-specific prevention, control, detection, diagnosis, and patterns of care; and ethical and social issues in medicine, and statements on ACP governance and intersocietal relations each represented 4%.

From 1975 to 1990, statements (14), in addition to CEAP recommendations, reflected the shift to health and public policy issues: 49% addressed health care delivery and financing; 24% focused on ethical, medicolegal, and social issues; 15% concerned educational issues; and 12% addressed health care problems of special populations and disease-specific conditions.

In this period, every statement, every conference, every deliberation of the College reflects the force and persistence of the impact of cost on medical education, medical research, and the practice of medicine. The College's proactive assumption of responsibility for socioeconomic issues in 1974, which it had eschewed in earlier years, came full circle a decade later. Another Toronto conference, the 17th Annual Leadership Conference in 1985, spelled out in bold terms (15, 16) the "hard choices in medicine" to be faced by the profession to the year 2000. Few issues were left untouched, as cost and quality of care, high technology, and ethical choices clashed in a field of complex and awesome challenges.

"we are treating our illness . . . at the expense of that which makes exceptional health care possible. In our search to be humane, we are foolish. Our consciences may be clear, but our pockets are empty, said guest challenger, Richard D. Lamm, Governor of the State of Colorado. "Our wants exceed our resources . . . medical miracles outrun the ability of the public to pay" (15).

"The world of medicine we have known in the past three decades is permanently changed—it will never again exist as we have known it..." responded Richard J. Reitemeier, viewing medicine to the year 2000 with some hard statistical facts. But, ". . . essential and critical, and of an importance equal to our provision of quality of care, is the public's expectation of the display of our humanistic qualities. The physician must be seen as safeguarding and defending the dignity and value of man and mankind" (16).

Tougher questions are on the agenda for the indefinite future. Nicholas E. Davies, President-Elect for the College's 75th anniversary year, recently asked his colleagues, "What do you believe to be the five most important issues facing the American health care system?" Bluntly, his respondents declared (17), ". . . cost, bureaucracy, access, technology and tort reform." Solutions are not easily offered, but Dr. Davies suggests that the profession might start by reclaiming the ground of the Hippocratic Oath: "Why not have physicians lead their patients and the nation in planning for health care in the next century? If this sounds paternalistic, blame Osler or Sydenham or the guy who first wrote it down, Hippocrates."

Are the College's founding purposes, expressed in the intent, if not the language of its first Fellowship Pledge, still valid after 75 years? On the difficult questions, recorded throughout the Archives of the College, there still falls the shadow of Hippocrates; rightly does the College's Mace (18) keep before its members in solemn assembly the reminder, "Life is short and the Art is long. "

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