The Conundrum of Medical Licensure for Physician Leaders

Today’s physicians have a variety of career choices unavailable to previous generations. The constantly changing and evolving medical landscape has ushered in jobs for physicians in various leadership roles, including, but not limited to, clinical informatics, innovation, and integration. Leadership opportunities exist not only in healthcare systems, but also in industry, government agencies, military service, and consulting and financial institutions.

The value of physician leaders has been discussed in many articles over the past several decades. A seminal study(1) conducted more than 20 years ago showed that physicians are adept at defining goals, priorities, and direction for healthcare organizations, and their leadership skills are highly valued by nonphysician leaders. In fact, in this study, physicians tended to underrate their leadership skills compared with ratings given to them by nonclinical leaders.

In 2014, The American College of Physician Executives changed its name to the American Association for Physician Leadership (AAPL), in recognition of the fact that, although not all physicians are executives or aspire to work in the C-suite, all physicians are capable of becoming leaders or at least demonstrating leadership behaviors. AAPL represents approximately 11,000 physician leaders in the United States and other countries. Many physicians in leadership roles have stopped practicing medicine, however, because the demands of clinical practice and a full-time leadership position may be incompatible.(2)

Career Impediments

Apart from carrying an active patient caseload, there are other barriers that may impede the careers of physician leaders. One significant barrier is medical licensure: physician leaders who have not actively practiced medicine for a period of time may be required to appear before state licensing boards to obtain or renew their medical licenses—for example, if they let their license expire and wish to reactivate it, or they seek a job in another state in which medical licensure is a condition of employment.

It is not uncommon for state medical boards to impose “reentry” requirements for clinically inactive physicians, even if they no longer intend to practice medicine. Catapano commented, “It is somewhat paradoxical that your physician leadership position may require a state medical license, but your state and other states may not consider you capable of clinical practice.”(3)

One could argue that organizations hiring physician leaders could remove medical licensure as a prerequisite for employment. However, the reality is that many physician leadership positions can be viewed as tantamount to the practice of medicine, because clinical judgments and determinations about patient care are central to many of those roles, even if the position does not involve actual hands-on patient care. Hence from a liability perspective, it is safer for organizations to require physician leaders to possess an active medical license in the state or states where those physicians conduct business.

A Case in Point

In my own case, after leaving a pharmaceutical job in Pennsylvania and moving to Florida, I was told that I did not meet the “practice requirement” of the Florida medical licensing statutes when I applied for a Florida license. The statutes require that physicians must have been engaged in active medical practice for at least two of the immediately preceding four years. I had not been in active practice since 1998, so I clearly did not meet Florida’s “practice requirement” for medical licensure. Although I held a Pennsylvania medical license, the state of Florida does not offer reciprocity as an avenue for licensure.

I was required to appear before the credentials committee of the state licensing board, whereupon I was told I would have to take a board recertification examination in my clinical specialty (psychiatry) in order to obtain a Florida medical license. The fact that I had had a robust academic career before I entered industry and had retained a faculty appointment as an adjunct professor at my medical school alma mater carried no weight—nor did my distinguished record of achievements, teaching, publications, and professional presentations.

Apparently, the only thing that mattered was the “laying on of hands.” I told the committee I had no intention of seeing patients, that I wanted to remain in medical or pharmaceutical management, and that I had received lifetime board certification in psychiatry in 1986, including subspecialty certification in psychiatric administration and management in 2002. How absurd, I thought, to be required to retake my boards, especially on learning that the recertification pass rate in psychiatry is 98%! I suppose passing the boards a second time would prove to the committee I was still competent, even though clinical competency and exam scores are not necessarily correlated.

At the credentials committee hearing, I met a physician who had recently moved to Florida and whose background and circumstances were similar to mine. After graduating from MIT with a degree in mechanical engineering and attending medical school, this physician had had an illustrious career in academic medicine as chairman of a neurology department. He became a researcher in the biotechnology industry. But he had not evaluated a patient since 2010. He, too, possessed lifetime board certification (in neurology), yet the credentials committee meted out the same sentence to him as it did to me. He was ordered to retake his specialty boards in order to receive a Florida medical license.

Caveat Emptor

I am not sure what happened to this physician, but in my case I complied with the committee’s requirement and sat for my boards again. I passed them and became recertified in psychiatry. Subsequently, I received a Florida medical license. However, it took 14 months from the time I initially submitted my application until I finally received my license.

The state of Florida is very transparent with physicians about medical licensure requirements (http://flboardofmedicine.gov/licensing/medical-doctor-unrestricted ). Under the best of circumstances, applicants for a Florida medical license should expect the entire process to take from two to six months from the time their application is received. Applicants are also advised not to make any commitments—employment or otherwise—based on expectation of licensure until they are actually licensed. Some physicians suffer significant costs by signing mortgages and committing to jobs prematurely. The Florida Board of Medicine does not “fast track” applications or accelerate applications at the expense of others.

Reentry Into Practice

Once away from practice for two or more years (different states have different cut-offs) physicians who would like to resume practicing medicine may be required to complete complicated and costly reentry programs. They may be required to undergo cognitive screening, extensive course work, continuing medical education programs, the Special Purpose Examination, clinical mentorship, and even preceptorships and mini-residencies. Reentry programs were implemented to ensure that physicians who have left practice for reasons other than discipline or impairment are competent to return to practice.

Two broad categories of physicians may require reentry programs: (1) physicians returning to practice in the same specialty; and (2) physicians returning to practice in a different specialty. When allowing physicians back into practice, licensing boards must strike a balance between patients’ safety and barriers to practice. Patients must be protected against unqualified physicians, but physicians should not have to overcome unrealistic or irrelevant requirements to reenter practice.

A Special Case

Physician leaders appear to be a special case given that reentry programs were not designed for them. Physician leaders generally do not see patients, or they have a limited practice. They may be seeking a leadership role in another state, or they may be required to hold medical licenses in multiple states, e.g., providing expert witness testimony, or conducting “medical necessity” reviews for large health insurance companies with members located in many states.

Rule number one for aspiring physician leaders is never let your medical license expire.

Furthermore, physician leaders may be at risk of losing their current medical licenses if states decide to adopt maintenance of licensure (MOL) policies, because one of the proposed components of MOL, “performance in practice,” requires that physicians demonstrate their competency through data derived from their own practices.(4) This provision of MOL could never be satisfied if physician leaders are no longer seeing patients; the requirement would have to be waived or amended.

Rule number one for aspiring physician leaders is never let your medical license expire. By maintaining an active medical license, most physicians who have given up practice will be able to change jobs, as long as they remain in state and in management (i.e., not practicing). Maintaining an active license, however, will not guarantee employment for physician leaders who move out of state, even if they refrain from practicing, which is what I discovered when I relocated to Florida. Nor will it facilitate a return to practice for clinically inactive physician leaders, even in state, because hospitals may set their own requirements for physicians to become credentialed and privileged. Even if physicians never come to the attention of the state licensing board, hospitals may require proof of competence from a reentry program or other type of retraining.

Clinical Experience and Quality of Care

Most physicians do not lose their clinical competencies simply because they leave practice to become hospital administrators or work in the health insurance or pharmaceutical industries. In fact, the discipline of pharmaceutical medicine is increasingly being recognized in many countries around the world. For patients enrolled in clinical trials, pharmaceutical physicians work closely with practicing physicians to advise them on a range of issues involving clinical assessment, diagnosis, and patient safety. Conceivably, working in the pharmaceutical industry may enhance physicians’ clinical skills and make them better doctors—not to mention that pharmaceutical physicians and medical licensing boards share similar objectives, namely, the protection of the public.

The amount of time a physician has been away from practice is a poor measure of physician competency.

The amount of time a physician has been away from practice is a poor measure of physician competency. It is important to consider what the physician did during his or her time off and consider additional measures of competency—social, cultural, and behavioral competencies that are not captured simply by asking a physician, “When was the last time you saw a patient?” A systematic review of the relationship between clinical experience and quality of healthcare found that physicians who have been in practice longer may actually provide lower-quality care to patients.(5)

The medical mainstream may prematurely judge physicians in industry—as well as physician leaders in other fields of medicine—as no longer worthy to serve the suffering. Clinical experience is certainly vital to medical leadership, but seeing patients is not necessarily the essence of a career in medicine. Robert M. Wah, former president of the American Medical Association (AMA), stated, “The ‘other’ box [administration, research, etc.] is vitally important to improving health care for our patients and our profession.”(6)

The evidence suggests that organizations and patients benefit when physicians assume leadership roles.

In many states, nurse practitioners and physician assistants with far less training than physicians may be able to practice medicine without physician supervision or with minimal supervision. Yet despite a nationwide shortage of both primary care physicians and physician leaders, those who have proven themselves to be extremely qualified may encounter reentry barriers that prevent them from obtaining or renewing their licenses. Is this policy really in the best interest of patients? The evidence suggests that organizations and patients benefit when physicians assume leadership roles.(7) Removing obstacles to medical licensure should be a priority.

A Shortage of Physicians

Exact figures on how many physicians suspend practice are not available, but the AMA estimated in 2011 that as many as 10,000 physicians could reenter practice each year.(8) Also according to the AMA, approximately 2% of physicians in the United States claim “administrative medicine” as their primary specialty.(9) Thus the magnitude of the licensure problem is significant. Moreover, the American Board of Medical Specialties does not recognize administrative medicine as a specialty. This further contributes to the shortage of physician leaders, or at least discourages physicians from pursuing careers in administration and management.

Medicine is too complex and specialized for a “one-size-fits-all” license.

Because licensing requirements vary by state and type of medical degree (MD or DO), a workable solution requires a national approach, perhaps offering alternative licensure tracks to physician leaders who no longer practice medicine—not necessarily because they are not interested in seeing patients, but more likely because to become an effective physician leader they no longer have the time to practice. The conundrum of medical licensure for physician leaders should be addressed with other efforts to reform medical licensure, such as the Interstate Medical Licensure Compact,(10) which attempts to resolve issues related to medical practice in multiple states.

Medicine is too complex and specialized for a “one-size-fits-all” license. The need for physician leaders, coupled with the need to create practical licensing options to allow physician leaders to do their jobs unencumbered by licensing boards bound by archaic rules and statutes, has never been greater. Furthermore, practicing physicians who have taken time off to raise a family or deal with pressing personal or health issues also need a straightforward way to reinstate their medical licenses and return to practice. As it stands, clinically inactive physicians seeking medical licenses as leaders and practitioners are navigating in unchartered and unfriendly waters.

References

1. Dunham NC, Kindig DA, Schulz R. The value of the physician executive role to organizational effectiveness and performance. Health Care Manage Rev. 1994;19(4):56-63.

2. Lazarus A. Adopting the CEO model: why physician executives should not be required to practice medicine. Physician Exec. 2008;34(4):24-26.

3. Catapano J. Re-entry: what every physician leader should know. Physician Leadership Journal. 2015;4(2):72-74.

4. Chaudhry HJ, Rhyne J, Cain FE, Young A, Crane M, Bush F. Maintenance of licensure: protecting the public, promoting quality health care. J Med Licensure and Regulation. 2010;96(2):13-20.

5. Choudhry NK, Fletcher RH, Soumerai SB. Systematic review: the relationship between clinical experience and quality of health care. Ann Intern Med. 2005;142:260-273.

6. Wah RM. Clinical experience is the essence of a career in medicine. American Medical News. 2012;55(2):22.

7. Angood P, Birk S. The value of physician leadership. Physician Exec. 2014;40(3):6-20.

8. For doctors who take a break from practice, coming back can be tough. Kaiser Health News. KHN.org ; http://khn.org/news/for-doctors-who-take-a-break-from-practice-coming-back-can-be-tough/ . Accessed September 8, 2016.

9. Physician Characteristics and Distribution in the U.S. Chicago, IL: American Medical Association, 2015.

10. Steinbrook R. Interstate medical licensure: major reform of licensing to encourage medical practice in multiple states. JAMA. 2014;312:695-696