key: cord-0935967-tr5ata0h
authors: Sawalha, Amr H.
title: Medical Licensure: It is time to eliminate practice borders within the United States
date: 2020-05-19
journal: Am J Med
DOI: 10.1016/j.amjmed.2020.04.015
sha: 20474a7400d4b18e7c55ca69249c37aff7ac135e
doc_id: 935967
cord_uid: tr5ata0h

nan

At this time of a national health emergency caused by the COVID-19 pandemic, indeed a global health crisis, we are reminded with the oath we took upon ourselves as physicians. We dedicated our lives to the most noble of all missions, saving lives and selfishly helping a fellow human in the time of utmost need. No matter what specialty or career path we take, it is always that "patients come first".

The ability to practice medicine is yet, as it should be, a privilege. Physicians are entrusted with human lives. It is, therefore, appropriate that medical education, training, and the ability to practice are closely scrutinized and highly regulated. Medical schools and residency programs have to maintain accreditations mandated by national standards (1) (2) (3) (4) . In addition, all physicians have to pass the three-step United States Medical Licensing Examination (USMLE), which is a prerequisite for obtaining a State-issued medical license to practice medicine in the U.S. (5) .

What is puzzling and defies logic, however, is that securing a medical license to practice medicine in one State does not allow for practicing the same type of medicine in another State in the same country. This contradicts the fact that accreditations and standards for medical education and training are regulated at the national level. Are patients living in this country different when they cross State lines? Does the human anatomy or physiology change when crossing the Mississippi River from Missouri to Illinois, or driving across the George Washington Bridge from New York to New Jersey for example? Does a physician really need to have four different medical licenses from Arizona, Colorado, New Mexico, and Utah to treat patients separated by the lines of the Four Corners Monument? Or is lupus (a disease I treat) different if a patient wakes up in an Eastern versus a Western time zone?

The status quo of restrictions imposed on the practice of medicine by State medical licensure does not make sense, and needlessly puts a tremendous pressure on the ability of physicians to do what they do best-take care of patients. Arguably, the current model of medical licensure in the U.S. restricts patients' access to care. A physician who is entrusted to practice medicine in one State in the U.S. should be entrusted to do the same all over the country. Needlessly having to apply and go through verification processes for another medical license for a different State entails significant effort, time, and resources that are better invested in taking care of patients. There is no value in contacting medical schools and residency training programs to verify the medical degree and training records when a physician is already licensed and practicing in good standing in another State. This laborious verification process has already been done by the State where the physician is already licensed. Do State medical boards not trust one another or is there a different motivation to keep this illogical bureaucratic process in place?

We realize that there are significant financial incentives that come to medical licensing boards from the initial application fees and maintenance fees, and we are not suggesting eliminating these sources of financial revenue. A possible solution is to require State medical boards, by a federal mandate, to recognize medical licenses issued by any of the States or territories within the country. Physicians will continue to be required to hold a medical license in good standing to practice medicine. However, this license can be issued from any State regardless of where the physician practices within the country. Maintenance of a good standing license to practice medicine will be through the original State that issued that license. Indeed, this is exactly the case for the Veterans Affairs (VA) health system, the clinical practice within the National Institutes of Health (NIH), and in military hospitals and clinics around the country. A medical license issued by any State allows practice in any health facility affiliated with these aforementioned health systems. Patient care is and should not be different if patients are military personnel, visit the NIH clinics, see their physician at a VA facility, or none of the above. So why not make this borderless medical licensure model a rule rather than an exception? Many millions of Americans receive care at VA or military medical facilities.

An alternative approach is for State medical boards to recognize medical licenses issued by any other State in the country and then use that as the sole basis for issuing a medical license by their own medical boards. If that system was to be adopted, then maintenance of such a license can continue to be issued from the State where a physician lives or wishes to practice, and again entails no loss of revenue to State medical licensing boards.

Let us advocate to extend the ability of our physicians to practice and remove these artificial inter-state restrictions that serve little if any good to the general public. We suggest that the waiver issued under the Emergency Declaration Act by the U.S. Department of Health and Human Services on March 13, 2020 for the "Requirements that physicians or other health care professionals hold licenses in the State in which they provide services, if they have an equivalent license from another State (and are not affirmatively barred from practice in that State or any State a part of which is included in the emergency area)" (6) be extended indefinitely.

Educational Commission For Foreign Medical Graduates

Accreditation Council for Graduate Medical Education

United States Medical Licensing Examination

Waiver or Modification of Requirements Under Section 1135 of the Social Security Act