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Is It Time to Rethink Postgraduate Training Requirements for Licensure?

Freeman, Bradley D. MD

doi: 10.1097/ACM.0000000000000881
Commentaries

Approaches to postgraduate medical training have evolved substantially in recent years, reflecting the complexity of the educational mission. Residency programs seek to produce clinicians who achieve board certification as an attestation of their competency. Certification criteria are established by the American Board of Medical Specialties, are consistent from state to state, and include periods of supervised instruction ranging from as few as three years (for primary care specialties) to much longer for selected disciplines. In contrast, minimum postgraduate training criteria necessary for licensure as an independent practitioner are established by state medical boards and vary significantly among and within jurisdictions. In most states, licenses can be granted to individuals who have completed as little as one year of postgraduate training. The discrepancy between the minimum time commitment necessary to become a competent physician and that to be licensed as an independent practitioner has implications for health care quality and safety. Data are lacking as to the number of licenses issued nationally to individuals who have only partially completed residency training and the nature of practices they pursue. Extrapolating from available evidence, these individuals may very well provide care inferior to those who have satisfied training requirements for certification eligibility and be more prone to problematic behavior resulting in disciplinary action. Efforts to establish more rigorous licensure criteria will require dialog between members of the academic community, professional organizations, state medical boards, and legislatures. The recently proposed Interstate Medical Licensure Compact may serve as a prototype for achieving this goal.

B.D. Freeman is professor of surgery, Department of Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri.

Editor’s Note: A Commentary by J. Orlowski appears on pages 23–25.

Funding/Support: None reported.

Other disclosures: None reported.

Ethical approval: Reported as not applicable.

Disclaimer: The opinions expressed are exclusively those of the author and do not reflect the views of Washington University School of Medicine in St. Louis, St. Louis, Missouri, or the Missouri Board of Registration for the Healing Arts, Jefferson City, Missouri.

Correspondence should be addressed to Bradley D. Freeman, Department of Surgery, Washington University School of Medicine in St. Louis, 660 S. Euclid Ave., Box 8109, St. Louis, MO 63110; e-mail: freemanb@wustl.edu.

As a member of both a university faculty and a state medical board, I have had ample opportunity to reflect on the postgraduate training requirements necessary to achieve competence as a clinician and those necessary to qualify for licensure as an independent practitioner. Ideally, these requirements should be identical. The fact that they are not has implications for health care quality and safety.

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Evolution of Postgraduate Training

In 2003, with the intention of lessening trainee fatigue and promoting patient safety, the Accreditation Council for Graduate Medical Education (ACGME) imposed a set of mandates on residency programs.1 These mandates, which were revised in 2011, decreased the cumulative time residents were able to devote to patient care, prompting academic health centers to rethink their approach to graduate medical education.2,3 To accommodate residents’ changing schedules, implementation of night-float services, development of intricate cross-coverage arrangements, consolidation or elimination of rotations, and increased reliance on midlevel providers have become commonplace.4,5 Structural changes to residency training have likewise occurred. For example, in surgical disciplines, the traditional paradigm of five years of general surgical instruction followed by subspecialty fellowship is being supplanted by early specialization models in which trainees focus exclusively on their field of interest after an abbreviated (i.e., 12- to 24-month) exposure to general aspects of surgical care.6 Residency programs in nonsurgical disciplines have adopted similar strategies.7 As a result, residents have less intensive clinical exposure, are less experienced at any given point in their education, and are less well rounded as clinicians relative to those engaged in training before the ACGME mandates went into effect.

Having served as a faculty member for a number of years, I feel that residents in their early years of training are not sufficiently skilled, knowledgeable, or experienced to be qualified for independent practice. My impression is hardly surprising. No residency program has as its goal the production of an independent practitioner prior to completion of training, certainly not after as few as 12 months. However, most states will issue an unrestricted medical license to these individuals.8

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Postgraduate Training Requirements for Board Certification and Licensure

Postgraduate training requirements to achieve board certification are established by the member boards of the American Board of Medical Specialties (ABMS) and are uniform throughout the United States.9 The minimum postgraduate training requirement for primary care disciplines is three years. For many other fields (e.g., invasive cardiology), the duration of postgraduate training is much longer.

In contrast, minimum postgraduate training requirements necessary for licensure as an independent practitioner are established by state medical boards and vary greatly.8 For example, the licensing board of South Dakota requires completion of a residency as a condition for granting licensure, whereas the Maine allopathic board and the allopathic and osteopathic boards in Nevada require three years of postgraduate graduate training to qualify for licensure. Boards in 15 states require at least two years of postgraduate training for licensure eligibility. Boards in the remaining states and territories require only one year of postgraduate training for licensure. In five states, boards providing oversight of allopathic physicians require more years of postgraduate training than boards overseeing osteopaths. For the remaining states with independent osteopathic and allopathic boards, training requirements for licensure are identical for osteopathic and allopathic graduates.8

Many states’ training requirements were established decades ago, when it was common for individuals to enter the labor force as a “general practitioner” after completing a rotating internship which provided brief exposure to core disciplines. With the proliferation of medical knowledge, rapid advance of technology, and evolution of medical and surgical specialties including those dedicated to primary care, the concept of the general practitioner has become antiquated if not obsolete.

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Should We Maintain the Status Quo?

Between 2011 and 2014, 60% of licenses issued in Missouri were granted to individuals who completed only one year of postgraduate training.10 Recently enacted legislation which eliminates postgraduate training requirements altogether may increase the number of licenses issued to those who have not completed residency.11 Whereas 76% of currently licensed U.S. physicians have been certified by ABMS,12 data are lacking as to the number of licenses granted nationally to individuals who have only partially completed residency training, the nature of practices they pursue, and the quality of care they deliver. Extrapolating from a growing body of literature that supports a positive relationship between board certification, health care quality,13–16 and professionalism,17–19 one might argue that individuals obtaining licensure who have not satisfied training requirements for board certification eligibility might very well provide care that is inferior to the care provided by those who have successfully achieved this benchmark, and be more prone to problematic behavior resulting in disciplinary action.

One argument put forth in favor of maintaining the status quo is the opportunity for trainees to “moonlight”—that is, to work independently outside the residency program structure. Moonlighting is considered by many as a means of gaining valuable exposure to independent practice. However, this argument runs counter to the logic of residency programs which are designed to provide graded autonomy based on experience level, cognitive ability as judged by performance on standardized testing, and frequent assessment and feedback by supervising faculty.20 The notion that residents are competent to practice prior to completion of this program of instruction suggests that at least some of this training is superfluous. Further, moonlighting is not embraced as a core component or requirement of any accrediting body. Similarly, to the extent that time devoted to moonlighting is in addition to that necessary to fulfill residency obligations, there is potential to exceed weekly duty hours limitations, thus circumventing the intent of ACGME mandates designed to minimize fatigue.1 Finally, individuals may be moonlighting in situations where they lack expertise (e.g., an internal medicine resident moonlighting in an emergency department where he or she may be called on to provide care to a pediatric or traumatized patient). A trainee physician should not be practicing in an unsupervised setting beyond his/her level of confirmed competence.

A second argument favoring the status quo of licensing physicians after minimal postgraduate training is that advanced practice nurses (and other midlevel providers) currently engage in independent practice though they possess comparatively less education and experience. However, advanced practice nurses are certified in one of several roles (e.g., as specialists or midwives) after completion of master’s or doctoral-level training in highly structured and accredited programs.21 Their scope of practice is defined in all 50 states, many of which require collaborative arrangements with supervising physicians. Accumulating evidence suggests that midlevel providers deliver high-quality, cost-effective care.22 Thus, whereas license might be granted to inadequately trained physicians to practice in settings in which they have little expertise, midlevel providers are specifically educated and credentialed in a narrowly defined focus.

Finally, access to health care is limited in many parts of the United States, particularly in rural areas and among the underinsured.23 Another argument in favor of the status quo is that physicians who have not completed residency training may provide a significant proportion of the care in these contexts, thus bridging significant gaps in the health care safety net. More stringent licensure requirements may have the effect of further impeding care delivery to vulnerable populations. This prospect may represent a powerful disincentive to legislators in considering statutory changes intended to enhance the competency of the health care workforce.

Medicine today is more complex and challenging than at any time in its history. Approaches to medical education have continuously evolved to reflect this reality while state medical boards have remained largely static in their training requirements for practice entry. This disconnect has resulted in an ever-widening discrepancy between the minimum time commitment necessary to become a competent physician and that to qualify for licensure. Correcting this discrepancy will require dialog between members of the academic community, professional organizations (e.g., medical associations and the Federation of State Medical Boards), licensing entities, and legislatures. Achieving consistency in licensing criteria nationally may prove challenging, given that oversight of the medical profession is under state purview. However, the recently proposed Interstate Medical Licensure Compact may serve as a prototype for doing so.24 The Compact, which is designed to streamline the licensure process among participating states, would require applicants to have successfully completed graduate medical education and specialty certification.24 To avoid creating multiple tiers of physician qualifications (and, by inference, competency), participating medical boards might find the rationale of extending these criteria to all individuals applying for independent licensure appealing. Finally, the potential for more rigorous licensure requirements to disrupt care delivery to at-risk populations cannot be ignored. Forethought must be given to strategies for minimizing such disruptions (e.g., expanded role for midlevel providers, application of distance-enabling technologies) as part of this broader effort intended to enhance health care quality and safety.

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