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dental education in the Unites States.

Kremers, Edward. Kremers and Urdang's History of Pharmacy, revised by Glenn
Sonnedecker. Philadelphia: J. B. Lippincott, 1976. A comprehensive history
of pharmacy in antiquity, the Middle Ages, Modern Europe and the United
States; it includes a chapter on the development of American educational
programs in the field of pharmacy.

Rothstein, William G. American Medical Schools and the Practice of Medicine: A History.
New York: Oxford University Press, 1987. A thorough history of medical
education in the Unites States, leading to a thoughtful analysis of the current


Joint Commission on the Accreditation of Healthcare Organizations. Accreditation
Manual for Hospitals. Chicago: Joint Commission on the Accreditation of
Healthcare Organizations, 1989. Addresses accreditation requirements for
hospitals. Issued annually.

National Board of Medical Examiners, Committee on Goals and Priorities. Evalua-
tion in the Continuum of Medical Education. Report of the Committee on Goals and
Priorities of the National Board of Medical Examiners. Philadelphia: National
Board of Medical Examiners, 1973. A comprehensive discussion of accredita-
tion, licensing, certification, and regulation in education for the health fields.

National Board of Medical Examiners. In Service to Medicine, 75th anniversary
publication. Philadelphia: National Board of Medical Examiners, 1990. Pro-
vides historical information about licensing in the health professions.

Young, Kenneth E., Charles M. Chambers, H. R. Kells, et al. Understanding Accredi-
tation. San Francisco: Jossey-Bass, 1983. A comprehensive discussion of the
accreditation process; explains how accreditation came into being, what it
entails today, the role of institutions, the role of accrediting bodies, and the
relationship between accreditation and regulation.


Professional and Voluntary


Professional and voluntary associations and organizations play a major
role in the U.S. health care system. Professional associations serve as the
collective voice of the various health professions, participate in and influ-
ence the regulation of those professions, and are a major force in educat-
ing and training health practitioners. Voluntary associations are signifi-
cantly involved in providing information to the public on health matters
as well as in funding biomedical research.

Gale's Encyclopedia of Medical Organizations and Agencies, the standard
reference in this area, lists approximately 5,000 such organizations func-
tioning at the international, national, and state levels.^ Not included in
this count are nearly 2,000 county medical societies^ and untold local
chapters of major national organizations such as the American Cancer
Society and the American Heart Association.

Professional associations, as the term suggests, are organized around the
concerns of particular health professions and draw their membership
exclusively or primarily from practitioners of those professions. Their
history in the United States dates to the founding of the first provincial
medical society in New Jersey in 1766.' Such organizations act as the
collective voice of the profession they represent. Their agendas commonly
include enhancing the position of their own profession within the larger
universe of health professions and in the eyes of governmental agencies
and the public at large. Additionally, they devote themselves to setting
requirements for licensure and maintaining standards for professional
practice; to encouraging research, innovation, and education; and to
legislative lobbying and similar "mutual protection" activities.'^ In terms



of the functions of the U.S. health care system as presented in this work,
professional associations are particularly active in two areas: education
and policy formulation and regulation. Activities such as publishing jour-
nals and offering continuing education programs for members are exam-
ples of the educational function. Professional associations implement the
policy formulation and regulation function through such activities as
standard-setting and legislative lobbying. Some professional associations
may also carry out activities in the realm of health promotion, and
virtually all are involved to some extent in providing their members with
practice-related products and services such as patient education brochures
and job placement services. (This activity is to be distinguished from the
U.S. health care system's function of providing goods and services, as
defined in Chapter 1.)

Voluntary associations are typically organized around some particular
disease, issue, or constituency other than a health profession. Examples
are the American Cancer Society, the Planned Parenthood Federation of
America, and New York City's Gay Men's Health Crisis. Depending on the
nature of a voluntary association, its membership may consist predomi-
nantly of lay persons, or it may be a mixture of both lay persons and
health professionals.

Voluntary health associations trace their beginnings in the United
States at least as far back as the 1861 founding of the Civil War Sanitary
Commission, devoted to promoting proper sanitation in Union Army
troop quarters and to improving medical treatment for sick and wounded
soldiers. 5 In peacetime, voluntary associations have made major contribu-
tions to the health of the American public by such means as promoting
public acceptance of programs to control the spread of communicable
diseases, initiating research projects, and sponsoring new health services
unavailable through normal public health channels.'' These purposes
coincide neatly with three of the six major functions of the U.S. health
care system: health promotion, biomedical research, and patient care.

In the latter part of the twentieth century, the health promotion
function is the most prominent of the three in the agendas of these groups.
The patient care activities of voluntary associations have largely been
taken over by other entities. However, a few voluntary associations do
participate directly in patient care — for example, by providing guide dogs
for blind people, as do the Lions Clubs, or by rendering first aid to victims
of disasters, as do Red Cross volunteers. A few other associations retain
more indirect roles in patient care by funding institutions, such as the
Shriners' burn institutes. The involvement of voluntary associations in the
research function falls somewhere between these two extremes. Volun-
tary associations are rarely directly involved in carrying out biomedical


research (with the notable exception of the American Red Cross); it is not
unusual, however, for voluntary associations to fund laboratories at
universities or other institutions.

Associations may occasionally move between the "voluntary" and
"professional" poles over time, one example being the American Heart
Association, which was originally organized as a professional society and
later reorganized as a voluntary association.^ In fact, the formation of
associations is itself a typical aspect of professionalization. The medical
historian Richard H. Shryock noted the deleterious impact of squabbles
between practitioners on the esprit de corps of physicians in the early
ninteeenth century. Their responses to this state of affairs included agitat-
ing for improved medical education, promulgating and enforcing codes of
professional ethics, and founding medical societies to place the collective
weight of the profession behind these enterprises.^ In a more modern
example, the increasing professionalization of homeopathy is evident in
the movement toward a uniform professional certification process for
homeopathic practitioners and the consequent formation in late 1991 of
the Council for Homeopathic Certification.^

The distinction between professional and voluntary organizations
becomes somewhat fuzzy in areas of alternative medicine, which lack
clear-cut credentialing procedures to define practitioners. For the most
part, however, it remains useful to think of professional associations as
those organized around the practice of specific health professions and of
voluntary associations as those devoted to specific diseases, problems,
issues, and constituencies in the health care universe.

The remainder of this chapter presents a typology of professional and
voluntary health associations, with examples of each type. It then consid-
ers the functions of the health care system that involve associations and
discusses the associations' activities that carry out those functions. Follow-
ing these sections are two case studies: one of a professional association,
the Illinois State Medical Society, and the other of a voluntary association,
the American Heart Association. The concluding section gives a brief
overview of current archival and records management activities among
health associations.


The universe of professional and voluntary health associations can be
classified with reasonable accuracy into eight categories of concern or



1. the medical profession in general;

2. medical specialties;

3. specific diseases or other medical conditions;

4. specific therapies or medical techniques;

5. allied professions and activities;

6. parallel professions;

7. alternative schools of medical practice; and

8. special concerns and constituencies.

As shown in Table 6-1, some of these categories contain both professional
and voluntary associations, in the senses defined above; some include
only one or the other.

In addition, one must note the existence of a class of umbrella
organizations whose memberships consist of other organizations or insti-
tutions rather than of individuals. Some of these umbrella organizations
fit relatively comfortably into one of the eight categories listed above.
Examples include the Federation of Orthodontic Associations and the
Federation of Prosthodontic Organizations, both of which include dental
specialty associations; the Council of Medical Specialty Societies, whose
constituency is clear from its title; and the National Health Council, whose

TABLE 6-1 Types of U.S. health associations, with examples



General medical

Allied professions
Parallel professions
Alternative schools
Special concerns

American Medical

American College of

American Society of Trans-
plant Surgeons

American Medical Writers

American Dental

American Holistic Medical

National Medical

American Red Cross

American Heart

Living Bank

National Health

Gay Men's Health Crisis


constituency includes a variety of general health associations (both pro-
fessional and voluntary). Other umbrella associations consist of institu-
tions or organizations belonging to classes treated in other chapters of this
work. The National Association of Medical Equipment Suppliers, for
example, relates to the health industries; the American Hospital Associa-
tion and the Council of Teaching Hospitals relate to health care delivery
facilities; and the Association of American Medical Colleges, the National
Association of Health Career Schools, and the American Association of
Colleges of Nursing relate to educational institutions.


The "arch-organization" under this rubric is the American Medical Asso-
ciation (AMA). Founded in 1847, the AMA exerted little influence during
its first fifty years and only began to assume its current influential position
after it was reorganized in 1901 into a confederation of state medical
societies. '° As currently constituted, the AMA is a professional guild
whose membership of approximately 300,000 comprises slightly less than
half of the M.D. physicians in the United States. (This proportion has
declined slightly in recent years with the proliferation of medical special-
ties and the resulting competition for membership from specialty socie-

Complementing the AMA are 54 state' ^ and nearly 2,000 county
medical societies whose membership consists of physicians practicing in a
particular locality. The organization of the medical profession at this level
considerably predates the formation of the AMA, and these societies are
separate from the AMA. In a handful of states, however, membership in
the AMA is a prerequisite to membership in the county and state societies.


Undoubtedly the most notable organization in this category is the Ameri-
can Red Cross, which has a professional staff of 23,000, nearly 2,800 local
chapters, and 1.2 million trained volunteers. "The mission of the Ameri-
can Red Cross is to improve the quality of human life; to enhance
self-reliance and concern for others; and to help people avoid, prepare for,
and cope with emergencies. "'^ In furthering this mission, the Red Cross
engages in myriad activities, notably blood bank services and disaster
relief — the latter an activity that typically involves patient care in the form
of first aid. The Red Cross also has major commitments in the area of
health promotion through such activities as blood pressure screening, first
aid training, and AIDS information campaigns. Perhaps uniquely among


voluntary health organizations, the Red Cross also operates its own
biomedical research facility, the Jerome H. Holland Laboratory, concen-
trating on blood-related research.


The professional associations in this category include about 80 specialty
societies of physicians practicing medical specialties such as cardiology
(American College of Cardiology), oncology (American Society of Clinical
Oncology), family medicine (American Academy of Family Physicians),
and the like.'^ These societies are similar in mission to the AMA, within
the limits imposed by the particular specialties. They tend to compete for
members with the AMA, which, as mentioned earlier, has lost member-
ship (in percentage terms) as medical specialties have proliferated in
number and complexity.

Alongside these societies exist numerous, generally smaller organiza-
tions devoted to subspecialties and interdisciplinary areas. Those related
to oncology, for example, number approximately twenty, including the
Society of Gynecologic Oncologists, the International Society for Preven-
tive Oncology, and the International Association for Comparative Re-
search on Leukemia and Related Diseases. Each major specialty features a
similar constellation of subspecialty and interdisciplinary associations.

The Council of Medical Specialty Societies also deserves brief mention
in this category. It is an umbrella organization founded in 1965 that now
includes twenty-four member societies organized "to provide a forum and
communications mechanism for the exchange of information . . . , to
identify and discuss public and professional issues of mutual interest or
concern, and to provide representation to appropriate organizations."''*

Related to the specialty societies but distinct from them are the
twenty-four certification boards organized under the American Board of
Medical Specialties. These certifying boards, consisting of outstanding
experienced practitioners, administer written and oral examinations in
the various specialties and subspecialties. In 1993, 39 specialty and 72
subspecialty certificates were offered by these boards.'^ Although the
members of a certifying board are likely to be members of appropriate
specialty societies, there is no formal structural connection between the


This category includes such well-known organizations as the American
Heart Association, the American Cancer Society, and the March of Dimes,



as well as others devoted to a wide range of disorders such as alcoholism,
Alzheimer's disease, and lupus erythematosus. These organizations typi-
cally include, in varying proportions, physicians, other health care profes-
sionals, and lay persons with a special interest in the disease or disorder in
question. A number of the major ones (e.g., the American Cancer Society)
are organized with state and local branches.^'' The American Heart Associ-
ation also has a network of fourteen scientific councils consisting primar-
ily of physicians practicing specialties related to its mission. These councils
represent the respective specialties in the association's decisions on allo-
cating grant support for research and in determining the content of the
organization's professional education activities and public education pro-
grams. ^^

Also deserving brief mention under this heading are the Shriners,^'^ a
fraternal organization with a special interest in children's health and in
burn research and treatment, and the 1.3 million-member Lions Clubs
International, a service association that takes a particular interest in
visually handicapped people^^ and funds goods and services such as
eyeglasses, guide dogs, mobile glaucoma-screening clinics, and vision

FIGURE 6-1 Shelters provided by the American Red Cross after the San Francisco
earthquake in 1906. Source: American Red Cross, National Headquarters



Organizations devoted to individual therapies and techniques are organ-
ized around a large number of entirely mainstream health activities, such
as organ transplantation and home health care; some less traditional but
increasingly accepted techniques, such as biofeedback and acupuncture;
and a handful of more controversial practices, such as cryonics (the
freezing of a person's body after death, in anticipation of a future cure for
the fatal disease) and Rolfing, a type of massage therapy. In the former
cases, the distinction between professional and voluntary associations is
generally clear. In the area of transplantation, for example, such profes-
sional associations as the Transplantation Society and the American Soci-
ety of Transplant Surgeons are complemented by voluntary ones, preem-
inently the Living Bank and Medic Alert's Organ Donor program. To take
an example from the opposite end of the spectrum, the Bay Area Cryonics
Society consists of "individuals interested in life extension through cryon-
ics. "^^ In such a case — lacking a precise definition of what constitutes a
"professional cryonicist"^^ — the distinction between professional and vol-
untary associations is difficult to draw with any degree of confidence.


Organizations devoted to professions such as nursing, medical records
administration, and medical writing are included under this heading. The
larger organizations, such as the 200,000-member American Nurses Asso-
ciation,^^ perform for their respective constituencies a range of functions
similar to those of the AMA. Smaller organizations have less ambitious
agendas, such as the American Medical Writers Association, which boasts
3,500 members and whose program consists largely of publications, an
annual conference, and a thorough continuing education program.^"*


This category edges into the allied professions on the one hand and the
"alternative schools" on the other hand. It clearly includes, however, a
short list of professions: dentistry, optometry, pharmacy, and veterinary
medicine. In general, these professions are characterized by the fact that
their practitioners hold doctoral level academic degrees or have under-
gone a comparably rigorous pattern of professional training. Each of these
has a national professional organization, such as the American Dental


Association and the American Optometric Association, similar in structure
and function to the AMA. Both of these associations also have networks of
associated state and, in the case of the American Dental Association, local


Again, there is some fuzziness of boundaries distinguishing alternative
schools from specialties or parallel professions. Nonetheless, some entities
clearly fall into the first category; among them are homeopathy, holistic
medicine, chiropractic, and naturopathy. Professional organizations in
this realm include, for example, the American Holistic Medical Associa-
tion, American Chiropractic Association, and American Association of
Naturopathic Physicians.


Possibly the preeminent voluntary alternative medicine organization is
the National Health Federation, the stated mission of which is to promote
"individual freedom of choice in matters relating to health"^^ — which in
practice means freedom to choose alternative as well as traditional thera-
peutic approaches. Some alternative medicine organizations seem to
straddle the boundary between professional and voluntary. To take one
example, the National Center for Homeopathy carries out both the educa-
tional function and the policy formulation and regulation function typical
of professional associations, the former through its associated National
Center for Instruction in Homeopathy and Homeotherapeutics,^^ the
latter through the Council for Homeopathic Certification. ^^ On the other
hand, this organization also devotes itself to health promotion in a fashion
typical of a voluntary association. For example, its annual meeting is open
to the public, and it sponsors local study groups whose clientele consists
largely of lay persons. ^^


The preeminent examples of this category are professional associations for
racial and ethnic minorities, such as the National Medical Association
(NMA), the professional society of African-American physicians. Founded
in 1895 and "[c]onceived in no spirit of racial exclusiveness, fostering no


ethnic antagonism, but born of the exigencies of the American Environ-
ment, the National Medical Association has for its object the banding
together for mutual cooperation and helpfulness the men and women of
African descent who are legally and honorably engaged in the practice of
medicine. "^^ Although the need for such a parallel professional associa-
tion has diminished somewhat in the ensuing years, the NMA continues
as a forum for the special professional concerns of African-American
physicians. Like the AMA, it publishes a journal and sponsors scientific
meetings and continuing medical education courses, although it focuses
on issues pertaining to economically disadvantaged and ethnic minority
patients. Other examples of this class of associations are the National Black
Nurses Association and groups of gay and lesbian physicians.


Organizations that include both health professionals and lay persons
organized around a topic of special concern compose this category. One
example is New York's Gay Men's Health Crisis, whose mission is "to
provide support services to people with AIDS, people with AIDS-Related
Complex (ARC) and the people who love and care for them; to [inform]
the public at large, individuals at high risk for human immunodeficiency
virus (HIV) infection, and health care professionals about AIDS; [and] to
advocate for fair and effective AIDS public policy and funding."^'' Other
similar groups include the Planned Parenthood Federation of America,
whose mission encompasses public information and public policy advo-
cacy related to contraception and reproductive health,^' and the National
Safety Council, whose mission is to "influence society to adopt safety and
health policies, practices and procedures that prevent and mitigate human
and economic losses arising from accidental causes and adverse occupa-

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