key: cord-1047284-55t4vayn
authors: Guth, Todd A; Luber, Samuel D.; Marcolini, Evie; Lo, Bruce M.
title: Physician reentry–A timely topic for emergency medicine
date: 2020-11-16
journal: J Am Coll Emerg Physicians Open
DOI: 10.1002/emp2.12317
sha: 60a268227bad5aa98d076826174f5df8ebe3731c
doc_id: 1047284
cord_uid: 55t4vayn

As physician workforce shortages persist, physician reentry is an important and timely issue for the specialty of emergency medicine. Physician reentry is defined as a return to clinical practice following an extended period of clinical inactivity not resulting from discipline or impairment. This review provides a general overview of the physician reentry published literature with a focus on the specialty of emergency medicine. Transition into a non‐clinical position, personal health, family issues, and career dissatisfaction all contribute to physicians leaving the workforce voluntarily. Previously, the majority of reentry physicians did not pursue additional training prior to returning to the workforce; however, regulatory agencies are now increasingly requiring additional training, standardized testing, and fitness to practice evaluations prior to restarting clinical work. The burden of proof is on the reentry physician to meet the appropriate requirements for licensure, certification, and credentialing prior to returning to clinical work.

The importance of physician reentry as a workforce policy issue trained or certified following an extended period of clinical inactivity not resulting from discipline or impairment. 2 It is important to keep the concept of physician reentry distinct from physician retraining and remediation. The term reentry is used for physicians in good standing who take time off from clinical practice whereas retraining refers to learning a new clinical area or procedure. 3 The term remediation is used for physicians who require additional training because of diminution of clinical skills, impairment due to substance use, or disciplinary actions. 3 Another concept, re-eligibility, is also relevant to understand for emergency physicians. Residency graduates must pass the written examination within 5 years of graduation and then pass the oral examination within 10 years of graduation. If an emergency physician does not complete specific milestones in a set period of time, then the physician will no longer be board eligible. The physician must participate in a program that reestablishes board eligibility, thus making him/her reeligible. 4 National medical organizations, such as the AMA and the Federation of State Medical Boards (FSMB), have seen physician reentry as an issue in need of a cohesive national policy. These organizations have had to rely on state medical boards, specialty certification boards, and local institutions to define the context and requirements for physicians to reenter clinical practice. 2, 3, 5 For example, no uniform standard length of time of physician inactivity exists, and individual states have been left to determine how clinical inactivity is defined if at all. The process of returning to clinical practice is coming under scrutiny because of the public's increasing demand for transparency regarding physician competence. 3 Criteria for medical licensure often do not include an expectation of ongoing clinical practice. Physicians who maintain a license but do not practice for a period of time may be reentering the workforce with uncertain competency to practice. 3 As physician shortages in the United States continue to be significant, the topic of physician reentry continues to garner attention as one possible solution to the shortfall of physicians and the demand for physician services in medically underserved regions. 6 Reentry physicians could also add to the physician workforce during a public health crisis, such as the recent severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. 7 Ultimately, state medical boards, specialty medical boards, and local institutions regulate the specifics of how a physician is able to reenter clinical practice. Specialty boards regulate the specifics for board eligibility in a given clinical specialty and state medical boards regulate physicians in a given practice jurisdiction. Local institutions delineate and grant clinical privileges to individual physicians based on training and certifications.

For emergency physicians seeking reentry, the American Board of Emergency Medicine (ABEM) provides specific guidance in regard to medical licensure and regaining certification if certification lapses, but there is not a specific policy on physician reentry. 9,10 According to ABEM policies, emergency physicians are considered board certified if they hold an active medical license and participate in the ABEM maintenance of certification requirements. The FSMB surveyed state licensing boards in regard to state-specific physician reentry requirements including the presence of a policy on physician reentry, requirements for standardized testing, continuing medical education, and the need for a fitness to practice evaluation before returning to clinical practice. 11 Appendix A reproduces a table from this report from the FSMB providing state-specific physician reentry information.

The aim of this review is to provide a general review of the published literature on the topic of physician reentry with a focus on the specialty of emergency medicine. Before describing the published literature, a general framework for physician reentry is presented. The review of the literature will identify the causes of physician clinical inactivity and barriers to reentry as well as outcomes of programs assisting physi-cians seeking reentry. Following the review of the literature, specific guidance, next steps, and special considerations for emergency physicians reentering the workforce will be presented as well as a charge to the specialty of emergency medicine to advocate for a more cohesive set of guidelines and definitions related to physician reentry.

The topic of physician reentry is influenced by a number of stakeholders including individual physicians, patients, specialty board, professional organizations, state medical boards, health systems, payers, and employers. The multiple perspectives represented by these stakeholders can make physician reentry complicated. Stakeholders appreciate the need to retain and ensure highly qualified practicing physicians while also providing the opportunity for physicians who have had a period of clinical inactivity to return to a successful professional career.

Issues related to personal autonomy, equity, public safety, compensation, funding, physician competence, and health care quality all affect the topic of physician reentry. In order to understand the complexity of the process, physicians considering reentry should reflect upon the personal, clinical practice, and legal and regulatory considerations as detailed in Figure 1 .

Personal considerations such as family dynamics, personal health, financial compensation, well-being, and work satisfaction can be extensive and varied. Personal considerations serve as both incentives and barriers to reentry. Clinical practice considerations include clinical competence, such as procedural skill, cognitive abilities, and confidence in addition to site-specific considerations that include practice setting, patient demographics, and patient acuity. Reentry physicians need to be thoughtful in identifying personal knowledge, and skill gaps while working to address those deficiencies for the practice environment under considerations. Legal and regulatory considerations must also be considered as medical liability, board certification, state requirements, and institutional regulations will dictate many of the details involved in the process of reentry. 

Some medical specialties, especially obstetrics-gynecology and anesthesia, have taken a proactive approach to physician reentry. The specialty of obstetrics and gynecology reports several small, specialtyspecific supervised clinical experiences based at specific institutions to allow for successful reentry into clinical practice. 11, 16, 18 The spe-cialty of anesthesia has the greatest number of specialty-specific publications related to physician reentry. Both high-stakes simulation assessments 19, 20 and individualized or advanced specialty training programs that include supervised practice 21, 22 were used to certify that anesthesiologists were ready to return to clinical practice. A review article focusing on the reentry of surgeons suggested continuing medical education as an opportunity to assist reentry for general surgeons, 23 and another review article focusing on gastroenterologists advocated for skills retraining for procedural competence prior to a return to clinical practice. 24 At the time of writing, there was no reentry program specifically designed for emergency physicians. Figure 2 . The process of seeking reentry is time intensive and likely to take a number of months, especially if additional training or a fitness to practice evaluation is required. Developing a plan and a timeline to complete the process of reentry will be important to navigate the process successfully. Reentry physicians should recognize that some aspects of the process will be out the individual physician's control, such as state-specific regulations and local credentialing requirements.

Although ABEM does not have an official policy on physician reentry, emergency physicians must also comply with the requirements for certification or regaining certification in order to be considered a board-certified emergency physician. 10 

The authors would like to thank Loren Rives, senior manager, Academic

Affairs, at the American College of Emergency Physicians for her continued support for the Academic Affairs Committee and for managing the activities of the subcommittee working on this objective and assisting with the logistics in the creation of this manuscript.

Dr. Guth 

A. The Center for Personalized Education for Physicians Denver, Colorado and Raleigh, North Carolina CPEP is a non-profit organization providing competence assessment and intensive education services to physicians and other healthcare professionals. Many of these clinicians are referred by licensing boards, credentialing bodies, and medical liability insurers, while a smaller number "self-refer." CPEP's Assessment and Reentry to Clinical Practice programs have worked with more than 2,000 physicians and others over 29 years. These programs give professionals the opportunity to demonstrate clinical competence and address areas of knowledge, skills, or judgment where improvements may be recommended.

B. Drexel Medicine Physician Refresher/Reentry Course Philadelphia, Pennsylvania Drexel's Physician Refresher/Reentry program offers a range of activities (education and assessment programs) for physicians who intend to return to active clinical practice, want to enhance their focus or area of interest, or want to prepare for admission to U.S. graduate medical education training programs.

C. Florida CARES Program Gainesville, FL The Florida Comprehensive Assessment and Remedial Education Services Program (Florida CARES) provides a specialty specific assessment of a physician's medical knowledge, decision making process, patient communication skills and level of psychological functioning. It is designed to help organizations such as the Board of Medicine and hospital medical staff's make decisions regarding whether a physician demonstrates the abilities and attributes to practice medicine in a safe and competent manner.

The LifeGuard Reentry /Re-Instatement program provides a pathway for physicians who wish to reenter the practice of medicine after an absence or for reinstatement of a license following a disciplinary action. We provide an unbiased, targeted assessment that can validate a physician's clinical skills and readiness to reenter the workforce. If deficiencies are identified, LifeGuard will provide a recommended path for remediation to address concerns in the most efficient manner possible.

The Texas A&M KSTAR Physician Assessment Program has partnered with the University of Texas Medical Branch (UTMB) in Galveston, TX to create the KSTAR/UTMB Health Mini-Residency program. This collaboration provides three-month, residency-based reentry education experiences for physicians who want to return to medical practice after an interruption in their career. Most specialty and subspecialty programs will be possible for those physicians who qualify.

F. University of San Diego Physician Assessment Education Program San Diego, California Since 1996, the PACESM Program has committed itself to promoting a culture of ongoing quality improvement and professional development in the medical field. It is our mission to better the quality of healthcare throughout the nation by offering assessment and remediation services to medical professionals. These assessments can be performed on practicing physicians as well as those who are seeking to reenter practice or obtain initial licensure. We also offer physician monitoring services through our Physician Enhancement Program (or PEP) and a number of continuing professional development (also known as continuing medical education) courses.

Reentry into clinical practice: challenges and strategies

Resources for Physicians Returning to Clinical Practice

Physician reentry into clinical practice: regulatory challenges

Guiding principles for physician reentry programs

Education to return nonpracticing physicians to clinical activity: a case study in physician reentry

Emerging Health Workforce Strategies to Address COVID-19

Pediatricians over 50 reentering clinical practice: implications for physicians and the regulatory community

Policy on Regaining Certification

Federation of State Medical Boards

Physician Reentry: a Concept Whose Time Has Come

Physicians reentering clinical practice: characteristics and clinical abilities

Inactive physicians: the state of our understanding

Facilitating physician reentry to practice: perceived effects of deployments on US Army pediatricians' clinical and procedural skills

Returning inactive obstetrics and gynecology physicians to clinical practice: the drexel experience

Facilitating physician relicensure and reentry into clinical practice

Lessons Learned in Physician Reentry

Simulationbased assessment and retraining for the anesthesiologist seeking reentry to clinical practice a case series

High-stakes simulation-based assessment for retraining and returning physicians to practice

Success and Challenge When Returning to Clinical Practice: a Case Series in Anesthesiologist Reentry

An advanced specialty training program in anesthesiology: a special educational fellowship designed to return community anesthesiologists to clinical practice

Continuing medical education, maintenance of certification, and physician reentry

Report of the AGA institute education and training committee task force on physician reentry

Medical education and reentry: finding ways to re-educate the physician who wants to come back to clinical practice

Physician Reentry-A timely topic for emergency medicine