Dr. X applies for a license to practice medicine in State A. When she submits the application for that license the state medical board will review the application and make sure there are no gaps or “red flags” in the applicant’s training or employment history. The board will send verification letters to the applicant’s postgraduate training programs, last places of employment, and personal references. A request for certification of Educational Commission for Foreign Medical Graduates (ECFMG) status will be requested for foreign medical graduates. The board will require primary source verification of the applicant’s medical education and licensing exam score(s) and verification of licensure status from every other state medical board where the applicant has either applied for, or been granted, a license. American Medical Association and Federation of State Medical Boards (FSMB) profiles will be requested to verify the applicant’s licensure and disciplinary history.
A short time later Dr. X finds that it would be convenient to see some of her patients just across the border in a neighboring state so she applies for a license in State B. The medical board in State B then begins the process of checking Dr. X’s credentials. Like the board in State A, the medical board in State B will demand primary source verification of:
medical education
postgraduate training programs
last places of employment
personal references
licensing exam score(s)
licensure status in other states
ECFMG certification status (if Dr. X is a foreign medical graduate)
In other words, State B will repeat the credentials verification process that was just done in State A. State B will essentially ignore the fact that all of this was just checked in State A.
Three months later Dr. X gets a job offer in State C. It’s an offer she can’t refuse so she applies for a license in State C. Once again the credential verification ball starts rolling. The whole process is repeated from start to finish, and the fact that two other state medical boards have just checked these same credentials is of no consequence whatever. In short, State C behaves as though the medical boards in states A and B are incapable of processing an application.
When the new job is not what she expected, Dr. X decides to go to work for a locum tenens firm. She then applies for three more medical licenses…
The entire process is redundant, expensive, slow, and frustrating. It is my opinion that the day is fast approaching when both physicians and the public will demand better. This constant re-invention of the wheel will be tolerated no more. State medical boards must respond to a more mobile society and to career paths that include many more stops along the way than they once did. I have said many times that if state medical boards can’t agree on a more efficient system then someone else, i.e., the US Congress, will do it for us. In truth, I think actual national licensure is unlikely, but it must be reasonable to expect that if the states can’t get the job done on their own then the federal government will at least mandate some very significant changes in the process. Unfortunately, change does not come easily, and although the boards cooperate with one another every day when it comes to fundamental licensure requirements there is some disagreement. For example:
All boards recognize the same exams. At one time, each state constructed its own medical licensing exam (and I don’t doubt that they varied considerably in both scope and difficulty), but that was a long time ago. Now every board recognizes the United States Medical Licensing Examination (USMLE) or, in the case of DOs, every state recognizes the COMLEX. Before the advent of USMLE, every state recognized either the National Board of Medical Examiners Parts Examination or the FLEX.
With very few exceptions, we all recognize the same medical schools.
With very few exceptions, we all recognize the same postgraduate training programs. Admittedly, some states require more postgraduate training than others (so there is a distinction to be made here), but that is the only really significant point on which licensing requirements vary from state to state. In any event, we all recognize the same programs.
We all ask the applicants to answer essentially the same series of questions pertaining to their past history.
We all require an ECFMG certificate from international graduates.
We all go through essentially the same laborious processes of verifying the applicant’s medical education, postgraduate training, employment history, criminal history, license history, and exam scores.
Of course, the devil, as they say, is in the details, and if medical licensure is anything it is a smorgasbord of details. That is as it should be. The details are important. Unfortunately, those details represent a bewildering array of differences in the rules, regulations, statutes, policies, and procedures of the various boards.
I have been attending the national meetings of the FSMB for about the past 20 years. One of the things that has frustrated me since day one is that many times every year someone will stand up and proclaim, “Well, the way we do it in our state is…” We then get a speech about how great some particular process is in Georgia or Florida or North Dakota or wherever. I always want to stand up and yell, “Who cares!” The problem is that the point the speaker is making almost invariably turns on some statute or administrative rule that is unique to that jurisdiction. If you come from a state that doesn’t have exactly the same regulation or legislation (and that usually includes everybody in the room except the speaker), then the point is academic. It shouldn’t be that way.
I also belong to Administrators in Medicine (AIM), which is made up primarily of medical board executives from around the country. Every year we have a session where the executives talk about all the new and exciting things that are happening in their home state. Each year we hear:
Some states are implementing mandatory continuing medical education requirements, and most have them.
Some are looking at licensing residents, while others license residents.
Some are ostensibly streamlining their licensing process, while some are not.
Some have an effective disciplinary process, while others have a less effective process.
Some require three years postgraduate training; some require two years; and some require one year.
Some require fingerprints as a condition of licensure.
The list could go on and on. In fact, each year the FSMB publishes a series of large booklets (the Exchange) that contains endless tables of data compiling the similarities and differences between the 70 medical boards in this country.
The purpose of the discussion at the AIM meeting is, of course, to facilitate a chance to learn from one another, but I always come away with a sick sort of feeling that what those discussions really accomplish is to illustrate a problem that few people in the licensure community ever talk about: The mostly rather minor differences in the 70 systems have created a morass.
Maybe, just maybe, the medical boards have reached the point in our collective development when we need to recognize that our similarities outweigh our differences. It makes no sense to have 70 sets of licensing requirements, 70 sets of disciplinary procedures, 70 sets of disciplinary standards, and 70 different sets of forms. It is imperative that boards develop a uniform process and then recognize true reciprocal licensure — soon. Of course, it won’t be easy. There are 50 state legislatures lurking in the background.
