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What Would Howard Beale Do About This?

Whitcomb, Michael E. MD

From the Editor

Several weeks after I graduated from medical school in 1965, I received a license for the unrestricted practice of medicine. Even today, some 40 years later, the idea that I could have legally begun to practice medicine at that point is a frightening thought. When my classmates and I received our licenses, we knew full well that we were not adequately prepared to open an office and begin seeing patients. Indeed, medical school graduates had recognized for decades that they needed additional clinical training before presenting themselves to the public as competent practitioners. Although they were not required to complete an internship and residency before entering practice, virtually all did. And it is worth noting that they did so even though they did not receive a generous stipend while pursuing additional training. They did it for the simple reason that it was the right thing to do!

The situation today is a bit different—but not much. To be licensed today, graduates of U.S. medical schools must successfully complete the sequence of examinations that compose the United States Medical Licensing Examination (USMLE) and complete one year of training in an accredited residency program. But is this really progress? Does anyone in the medical community really believe that it is reasonable to grant a license for the unrestricted practice of medicine after a graduate has had only one year of residency training? Probably no one believes this, since the profession has made it clear that doctors are not prepared for the independent practice of medicine at that point. For example, professional standards require second-year residents who are already fully licensed to be supervised as they provide care during the remainder of their training, and certifying bodies—the bodies that represent to the public that a physician is competent to practice a particular specialty—grant certification only after a physician has completed an accredited residency program and passed the required certifying examinations.

Clearly there’s a big disconnect here: State governments that are charged with protecting the health and well-being of the public are providing licenses for the unrestricted practice of medicine to physicians even though the profession does not deem these physicians to be competent to practice medicine. This makes no sense!

Why does this situation exist? Perhaps because state legislators—those who craft the medical practice acts that govern licensure—are unaware of the current situation, or don’t realize that one year of residency does not really prepare a physician for the independent practice of medicine. I can understand how that might be the case, since legislators are not likely to be familiar with the specifics of how doctors are being educated. But what I don’t understand is why the profession has allowed this situation to exist. After all, doesn’t the profession have a responsibility to ensure that those who are not adequately prepared should not practice medicine? If so, shouldn’t the profession take a responsible stand on how licenses for the unrestricted practice of medicine are granted by the states? The fact that most medical school graduates who plan to practice are still “doing the right thing” and pursuing more training than the states require only emphasizes the wrongheadedness of today’s licensure practices.

I must admit that I am also frustrated by how this issue has been addressed within the academic medicine community. I have yet to talk to a single individual in that community who believes that the current situation makes sense. Not only that, many assert that the requirement that medical students must pass USMLE Steps 1 and 2, to include the recently implemented Clinical Skills examination, distorts the proper design and conduct of the undergraduate medical education program. I know from experience that many faculty members argue against curriculum reforms because they believe that the proposed reforms might adversely affect the ability of their students to pass the licensure examinations. Some schools actually build time for students to study for the examinations into the structure of their curricula. But beyond this, since the academic medicine community is responsible for preparing physicians for practice, doesn’t it have a responsibility to call attention to the fact that doctors are being granted licenses before they are adequately prepared to practice?

The two organizations that sponsor the USMLE—the National Board of Medical Examiners (NBME) and the Federation of State Medical Boards (FSMB)—know full well that the current situation makes no sense. Both organizations have acknowledged that licensure should not be granted until a physician has completed at least three years of residency training. While that would be better than the current situation, such a “one size fits all” approach doesn’t really make sense either. Why should an internist receive a license after he or she has completed three years of residency training, while a surgeon—after doing the same thing—would be eligible to receive a license after completing only 60% of the training he or she needs? Indeed, a committee convened by the NBME concluded that full licensure should be granted “only when formal education is completed and when the physician has been certified as competent to practice medicine independently.”1

The FSMB and the NBME are both engaged in activities intended to make the licensure process more rational, but I am not optimistic about the outcome of their well- intentioned efforts. After all, the report of the NBME committee noted in the previous paragraph was issued 33 years ago. And eight years ago, the FSMB House of Delegates adopted the position that “all applicants for licensure should have satisfactorily completed a minimum of three years of postgraduate training.”2 Despite the fact that the FSMB is the membership organization for the state medical boards, not a single state has responded adequately to that position.

So what is to be done? The challenge involved is enormous. To make the licensure process more rational, state legislatures would have to make changes in existing laws, since with very few exceptions, such laws govern the state requirements for initial licensure. The fact that this has not occurred already, despite the positions taken by the NBME and the FSMB, makes clear how difficult it will be to accomplish the needed changes.

I believe that the changes needed in licensure laws will not occur unless public advocates get involved. Even though some in the profession are wary of embarking on this strategy, shouldn’t the public know about the current situation? Shouldn’t they be in a position to hold their elective officials responsible for making changes in the licensure laws that are consistent with the standards the profession has established to say when a physician is adequately prepared to practice medicine? The public does have that right, and the academic medicine community that benefits so greatly from public support ought to take the lead in seeing to it that this occurs. So what should the academic community do?

For starters I would like to see the organizations that represent the academic medicine community take a highly visible public stand on the issue. Why? Because the current situation places members of the public at risk of being cared for by physicians who are not truly competent to practice, and it undermines to some degree the quality of undergraduate medical education by requiring medical schools to tailor their programs to accommodate the scheduling of the licensure examinations. At the same time, each medical school could develop a communication strategy that would inform the local citizenry and their elected representatives about the current situation and why changes are need to serve the public’s interest.

And if those approaches don’t by themselves lead legislators to change the licensure laws, then maybe the academic medicine community needs to play the role of Howard Beale in the 1976 award-winning movie “Network.” Do you remember his plea to the public watching him on the nightly television news program he anchored? “Get up out of your chairs, open the window, stick your head out, and yell, I’m mad as hell, and I’m not going to take this anymore!” Wouldn’t that be something? Wouldn’t that catch the attention of lawmakers and convince them that they had better do something? I would hope so.

Of course, this is a tongue-in-cheek suggestion. But even less dramatic approaches will be frowned upon by many in the academic medicine community, who will say that it is too risky to get involved in this issue nationally, and certainly too risky for medical schools to take the lead in their states. But that doesn’t dissuade me from suggesting it should be done. After all, isn’t it the right thing to do?

Michael E. Whitcomb, MD

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1 Evaluation in the Continuum of Medical Education. Report of the Committee on Goals and Priorities of the National Board of Medical Examiners. Philadelphia: National Board of Medical Examiners, 1973.
2 Maintaining State-based Medical Licensure and Discipline: A Blueprint for Uniform and Effective Regulation of the Medical Profession. Euless, TX: The Federation of State Medical Boards of the United States, Inc., 1998.
© 2006 Association of American Medical Colleges