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On The State Licensing Process of Physicians

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By State Medical Boards

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By ROBERT JAMES CIMASI; MHA, ASA, FRICS, MCBA, AVA, CM&AA, CMP

By TODD A. ZIGRANG; MBA, MHA, ASA, FACHE

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Every state and the District of Columbia require the licensure of all allopathic (M.D.) and osteopathic (D.O.) physicians [1] Although the specific criteria for licensure vary by state, each state requires candidates to submit proof of completion of the requisite number of years of graduate medical education and passage of examinations verifying that “the physician is ready and able to practice competently and safely in an independent setting [2].

Moral Character

Additionally, a physician applying for licensure is typically required to have “good moral character,” absent his or her involvement in illegal activities [3] Most physicians satisfy the exam requirement by submitting proof of their successful completion of the United States Medical Licensing Examination (USMLE) or the Comprehensive Osteopathic Medical Licensing Examination (COMLEX-USA) to the licensure board [4] However, as some practicing physicians may have been licensed under a previously administered exam, certain state licensing boards may consider a combination of other examinations sufficient to meet licensure requirements, so long as those exams were completed prior to 2000 [5]

Of State Medical Boards

The licensure of physicians is governed by a state medical board, the “primary responsibility” of which board, according to the Federation of State Medical Boards, is to “protect consumers of health care by ensuring that all physicians…are properly licensed and comply with various laws and regulations pertaining to the practice of medicine[6] To accomplish this goal, state legislatures have delegated certain powers to the state’s medical board, including the power to grant, suspend, and revoke licenses; conduct investigations into complaints against physicians; and, release guidelines related to best medical practices [7] State medical boards have traditionally consisted solely of physicians; however, there has recently been an increase in the number of non-physician board members on state medical boards [8].

History

Over the last 50 years, state medical boards have faced intense scrutiny regarding their commitment to disciplining physicians based on quality concerns [9] In 1960, the American Medical Association (AMA) heard “sobering” facts from the Federation of State Medical Boards that “much confusion over the definitions and objectives exists” related to state medical board enforcement of medical standards [10] From 1963 to 1967, 0.06% of all physicians were subject to discipline, while in 1981, 0.14% of all physicians were subject to discipline, due in large part to the problems identified by the AMA [11] Although the rate of physician discipline rose eightfold by the mid-1990s, to date, there are continuing concerns regarding state medical board enforcement of quality standards.

A March 2011 report by advocacy group Public Citizen found that over 55% of physicians who faced clinical privilege disciplines by hospitals from 1990 to 2009 did not have a corresponding action from a state medical board [12] Additionally, in 2011, state medical boards imposed 3.06 “serious disciplinary actions” (e.g., revocations, surrenders, suspensions, and probations of medical licenses) per 1,000 physicians, an increase from the 2010 rate of 2.97 per 1,000, but a decrease from the 2004 rate of 3.72 per 1,000 [13] Numerous reasons have been offered to explain the disparity in quality enforcement by state medical boards, the most prominent being that physicians are loath to report fellow physicians for major disciplinary actions such as licensure revocation[14]

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nurses

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Assessment

Other reasons include a focus by state medical boards on “character-related misconduct” over clinical quality standards [15] as well as a lack of resources to investigate and enforce quality standards, which forces state medical boards to rely on physicians and hospitals to “police” themselves [16].

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 REFERENCES

[1]       “State Medical Boards: Future Challenges for Regulation and Quality Enhancement of Medical Care,” By James N. Thompson, Journal of Legal Medicine, Vol. 33, No. 9 (January-March 2012).

[2]       “State Medical Boards: Future Challenges for Regulation and Quality Enhancement of Medical Care,” By James N. Thompson, Journal of Legal Medicine, Vol. 33, No. 9 (January-March 2012); “Healthcare Valuation: The Four Pillars of Healthcare Value,” By Robert James Cimasi, MHA, ASA, FRICS, MCBA, AVA, CM&AA, Hoboken, NJ: John Wiley & Sons, Inc., 2014, p. 449-450.

[3]       “Medical Practice: Education and Licensure,” in “Legal Medicine,” By S. Sandy Sanbar et al., 6th Ed., Mosby, 2004, p. 81.

[4]       “Medical Licensure,” American Medical Association, 2014, http://www.ama-assn.org/ama/pub/education-careers/becoming-physician/medical-licensure.page, (Accessed 12/19/14); “COMLEX-USA,” National Board of Osteopathic Medical Examiners, 2014, http://www.nbome.org/exams-faq.asp (Accessed 12/19/14).

[5]       “Medical Licensure,” American Medical Association, 2014, http://www.ama-assn.org/ama/pub/education-careers/becoming-physician/medical-licensure.page, (Accessed on 12/19/14); “Healthcare Valuation: The Four Pillars of Healthcare Value,” By Robert James Cimasi, MHA, ASA, FRICS, MCBA, AVA, CM&AA, Hoboken, NJ: John Wiley & Sons, Inc., 2014, p. 450.

[6]       “What is a State Medical Board?” Federation of State Medical Boards, 2014, http://www.fsmb.org/policy/what-is-a-smb-faq (Accessed 12/19/14).

[7]       “What is a State Medical Board?” Federation of State Medical Boards, 2014, http://www.fsmb.org/policy/what-is-a-smb-faq (Accessed 12/19/14).

[8]       “What is a State Medical Board?” Federation of State Medical Boards, 2014, http://www.fsmb.org/policy/what-is-a-smb-faq (Accessed 12/19/14); “Character, Competence, and the Principles of Medical Discipline,” By Nadia N. Sawicki, Journal of Health Care Law & Policy, Vol. 13, No. 1, 2010, p. 291.

[9]       “Character, Competence, and the Principles of Medical Discipline,” By Nadia N. Sawicki, Journal of Health Care Law & Policy, Vol. 13, No. 1, 2010, p. 287, n. 7; “To Err is Human: Building a Safer Health System – Summary,” Institute of Medicine, 2000, http://www.iom.edu/~/media/Files/Report%20Files/1999/To-Err-is-Human/To%20Err%20is%20Human%201999%20%20report%20brief.pdf (Accessed 12/19/14).

[10]     “Medical Licensure Statistics for 1960,” Journal of the American Medical Association, Vol. 176, No. 8 (May 27, 1961), p. 694.

[11]     “Medical Licensing Board Characteristics and Physician Discipline: An Empirical Analysis,” By Mark T. Law & Zeynep K. Hansen, Journal of Health Politics, Policy and Law, Vol. 35, No. 1 (February 2010), p. 66.

[12]     “State Medical Boards Fail to Discipline Doctors with Hospital Actions Against Them,” By Alan Levine et al., Public Citizen, March 2011, http://www.citizen.org/documents/1937.pdf (Accessed 12/19/14).

[13]     “Public Citizen’s Health Research Group Ranking of the Rate of State Medical Boards’ Serious Disciplinary Actions, 2009-2011,” By Sidney M. Wolfe, M.D., et al., Public Citizen, May 17, 2012, http://www.citizen.org/documents/2034.pdf (Accessed 12/19/14).

[14]     “Medical Boards are Too Lax, Critics Claim,” By Wayne J. Guglielmo, MA, MedScape, October 17, 2014, http://www.medscape.com/viewarticle/833141 (Accessed 12/3/14);

[15]     “Character, Competence, and the Principles of Medical Discipline,” By Nadia N. Sawicki, Journal of Health Care Law & Policy, Vol. 13, No. 1, 2010, p. 287.

[16]     “Medical Licensing Board Characteristics and Physician Discipline: An Empirical Analysis,” By Mark T. Law & Zeynep K. Hansen, Journal of Health Politics, Policy and Law, Vol. 35, No. 1 (February 2010), p. 90; “Medical Licensure Statistics for 1960,” Journal of the American Medical Association, Vol. 176, No. 8, May 27, 1961, p. 694.

NC Update: H543v2 – 04152015

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SUBSTANCE ABUSE AND IMPAIRED PHYSICIANS

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On Physician Health Programs [Help or Hindrance?]

[By Eric A. Dover MD]

Approximately 10-12% of physicians will develop a drug or alcohol problem at some point during their career. If physicians are impaired, they should be able to seek help from a firm but supportive and fair resource—one that demands sobriety and can determine when physicians are safe to practice.

About PHPs

Physicians with substance use disorders often seek the assistance of a state physician health program (PHP). Some physicians engage willingly with PHPs, but most are compelled to do so either by their hospital or their board of medicine.  PHPs meet with, assess, and monitor physicians who have been referred to them for substance use or other mental and behavioral health problems.

In most states, physicians who comply with any and all demands of the PHP often may continue to work, provided their sobriety is ensured through drug testing and other means. Many state boards of medicine rely completely on the PHPs for guidance about how to deal with impaired physicians.  PHPs are therefore extremely powerful.

The Problem

The problem with PHPs, though, is that despite their enormous power, they are generally barely known to most physicians and often operate with little oversight and no real means of appealing their recommendations.

To compound matters, evaluation/treatment centers and PHPs are often financially dependent on one another: Centers depend on referrals from PHPs for their viability and, reciprocally, PHP regional and national meetings are often heavily sponsored by these centers.

***

Stress

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Largely Unknown Practices

Because PHP practices are largely unknown to physicians until they themselves are referred to one, physicians who do register complaints about standard PHP practice are often dismissed as bellyaching. But, some voices of concern have been heard.

For example, several years ago, a paper was published in the Journal of Addiction Medicine outlining concerns about standard PHP practice, which included the points raised above; along with others.

More recently, a group of North Carolina physicians complained about their state PHP to the state auditor. The auditor conducted an investigation and found poor oversight of the PHP by both the state medical society and the board of medicine, a lack of due process for physicians who disputed the PHP’s evaluations and/or recommendations, and multiple instances of potential conflicts of interest.

And so, some authorities suggest a national federation of PHPs to implement national standards for its members and commence routine audits of its members.

Assessment

Doctors who are unsafe to practice medicine ought to be prevented from doing so, but every doctor who enters any kind of treatment or monitoring program should be treated respectfully, and fairly, monitored appropriately, and have legitimate avenues of appealing decisions about their care.

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ABOUT

Dr. Eric Dover is a board certified family practice and primary care physician in Portland, Oregon. He is a graduate of the University of California at Los Angeles [UCLA] School of Medicine.

Conclusion

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Is Medical Licensing Really Necessary?

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Licensing Doctors – Do Economists Agree?

[By Staff Reporters]

In the US, the various state medical boards dictate the rules for physician licensure and discipline. Would-be physicians must complete an approved medical training program and pass a standardized test.

Scope-of-practice laws prohibit other health professionals from offering similar services.

***

Google School of Medicine

[Google School of Medicine]

***

Given the resources involved in licensing doctors, taxpayers might be surprised to learn that the link between licensing and service quality is tenuous at best.

In fact, some economists like Shirley Svorny PhD, who’ve examined the market for physician services, may view medical licensing as a constraint on the efficient combination of inputs and a drag on innovations in health care and medical education.

Assessment

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Conclusion

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