The COVID-19 pandemic has exposed many vulnerabilities in the U.S. health care system. While shortages of safety equipment and ventilators have been widely reported, the shortage of physicians and staff to manage patients in respiratory failure is also a major concern. Given the reported conditions throughout northern Italy with hospitals operating over capacity and exhausted medical personnel, the same concern arises in the United States. While some may be quick to write off the coronavirus health care crisis in Italy as unsurprising given the smaller size of Italy versus the U.S., a country’s capacity to respond to a pandemic is not so simple. Although there are more doctors in the U.S. than Italy, their ability to work is geographically restricted, making the redeployment of doctors to needed areas a complicated affair.
The United States does not have a single nationwide medical license allowing physicians to practice medicine across all 50 states. American doctors are only permitted to practice in states where they have been granted a medical license. The medical license application process in a new state is often costly and time-consuming. During an event such as the COVID pandemic, the problematic nature of our licensing system may be exposed as physicians from around the United States willing to help during a crisis may not be able.
Currently, many states are waving requirements for medical professionals to obtain licensure in their state as long as they hold a valid license in another U.S. state, a response to personnel shortages from the COVID-19 crisis. The goal is to provide the hardest-hit areas with as much medical manpower as possible to manage the expected influx of critically ill patients. However, not all states are waving requirements. States such as Arkansas, Missouri, Nebraska, Virginia, Illinois, and Kansas (among other states) have chosen to keep their current licensure requirements in place, possibly leaving themselves at risk for physician shortages should the COVID-19 situation worsen.
Although this emergency waiver of state medical license in states that have chosen to do so is likely temporary, it raises the question of why the United States maintains a system in which doctors must get separate state licenses. All state medical licenses require medical students to take and pass the same grueling medical licensing exams called the USMLE (or COMLEX for Osteopathic medical students). US-trained or foreign graduates, must take and pass all four test series in order to practice medicine in the United States, regardless of location. The scores are transmitted to the Federation of State Medical Boards (FSMB,) which transmits this information to individual states licensing boards.
As both the president of a medical education company and also an emergency teleradiologist, I am no stranger to the frustrating world of United States medical licenses. Regularly, I spend half my time working with medical students to prepare them for board licensing exams and advise them on how to navigate residency. For the past decade, I have been lecturing and tutoring across the U.S. and abroad to improve student preparedness for the USMLE and COMLEX. I also spend time explaining how a student’s USMLE or COMLEX scores and possible failures can affect their chances of obtaining a medical license, showing them how these exams fit into the broader, complex system of medical licensure.
As a radiologist, I work with a company providing remote overnight and weekend radiology coverage for more than 150 hospitals across more than 16 states and the District of Columbia. In order to do radiology work, I hold 16 different medical licences. For every hospital in every state in which we provide coverage, all of the radiologists must have a medical license in that state, in addition to a license from the state where they reside. Each of these states has its own unique license application paperwork and fees, which largely ask for the same information and rely on the exact same test scores.
The cost of each application is not just fees, which typically runs in the hundreds of dollars per application with renewal every 2-3 years. The far bigger costs are the enormous volume of paperwork required and the extreme time delay — up to 6-9 months in some states — for an already licensed physician to obtain an additional state license. Our radiology group has a full-time team of staff devoted solely to applying and renewing licenses for our doctors. Counting application fees, the cost of acquiring each license easily reaches several thousand dollars.
Licensure in a state-by-state fashion should not be required to practice teleradiology or telemedicine. Just like during the COVID-19 epidemic. If doctors have to wait for states to waive licensure requirements to treat patients, it may cause delays in care costing lives. It would be fair to expect that once a doctor has a license in one state, it is straightforward to obtain a license in another state. For example, I had to wait nine months to obtain a license in Texas despite already holding ten other state licenses at the time. This kind of delay affected every doctor in my group and prevented us from providing much-needed coverage to hospitals in that state.
With the medical care costs continuing to rise, streamlining the licensure process would make it easier for our nation’s physicians to better respond to the medical needs across the country — especially during nationwide medical crises. The increasing use of telemedicine beyond the radiology, into specialties such as internal medicine, neurology, psychiatry, and even ICU care, will require more physicians to apply for and hold multiple state licenses. Because all physicians already take the same exams and use the same national processing center, it seems logical we should adopt a single national license. Such a licensure system would not only be more cost-effective, but also greatly help the United States’ ability to respond to large scale medical events in the future.
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