Position Statements

Position of the Federation of State Medical Boards in Support of Postgraduate Training and Licensure Standards

Background and Statement of the Problem

The accepted continuum of medical education in the United States includes four (4) years of medical school and three (3) years postgraduate training. Graduation from medical school is not deemed sufficient to prepare a physician to offer unsupervised medical care to the public in any jurisdiction. The purpose of postgraduate training programs is to prepare physicians for the independent practice of medicine. As such, resident physicians progressing through postgraduate training programs are expected to assume increased responsibility for making independent medical decisions regarding patient care. State medical boards are mandated to protect the public by regulating the practice of medicine, wherever it occurs. Recognizing resident physicians will provide varying degrees of unsupervised patient care throughout their training, it is imperative that effective systems be in place for the oversight of resident physicians.

Following a study of the status of resident licensure in the United States, the Federation of State Medical Boards adopted a policy in April 1996, which was reaffirmed in May 1998 to improve and strengthen the system of monitoring and regulating resident physicians. Because of the small but significant number of problematic residents that may endanger patients, the Federation advocates medical board regulation of all physicians enrolled in postgraduate training programs. Specifically, this policy recommends all applicants for postgraduate training programs successfully complete the United States Medical Licensing Examination (USMLE) Steps 1 and 2 or Parts 1 and 2 of the certifying examination administered by the National Board of Osteopathic Medical Examiners (NBOME) prior to acceptance into a postgraduate training program. Passage of such examinations would be an appropriate indicator that applicants have obtained a minimum level of cognitive knowledge necessary to enter postgraduate training. Federation policy further recommends all resident physicians obtain a training permit or limited license that would restrict the physician to the supervised practice of medicine within the confines of the residency training program. The Federation also recommends program directors be required to provide annual reports to state medical boards that would include any serious problems experienced by a resident, as well as recommendations for permit renewals.

In addition to addressing the regulation of resident physicians, the May 1998 Federation policy strengthens requirements for initial licensure by recommending all applicants for full and unrestricted license to have completed three (3) years of progressive postgraduate training in an ACGME- or AOA-approved postgraduate training program, including completion of the third year of postgraduate training (PGY3). Currently, requirements for post graduate training vary from one (1) to three (3) years among licensing jurisdictions. Therefore, in some states, resident physicians who have obtained full and unrestricted licensure following one (1) year of residency training engage in employment outside the residency program, typically in emergency settings. "Moonlighting" is a common, albeit controversial, practice. Across all specialties, AMA surveys have estimated the frequency of moonlighting at 23 to 37 percent. Following only one year of postgraduate training, physicians may lack sufficient training and experience in the aspects of primary health care necessary to provide unsupervised patient care, especially in an emergency setting. Due to the intense work schedules required by residency programs, these physicians may be providing medical care to an unsuspecting public while impaired by significant fatigue. These "moonlighting" physicians are typically those with large educational debts and family obligations and therefore may be more likely to exceed the limits of an already rigorous schedule demanded within their training programs. Such practices potentially compromise patient safety. Additionally, resident physician moonlighters provide unsupervised care, many with inadequate training and experience. Requiring physicians to complete a minimum of three (3) years of postgraduate training before obtaining full licensure would address patient safety concerns resulting from the practice of "moonlighting."

Recommendations and Conclusions

1. All applicants for postgraduate training shall have satisfactorily completed Steps 1 and 2 of the United States Medical Licensing Examination (USMLE) or Parts 1 and 2 of the certifying examination administered by the National Board of Osteopathic Medical Examiners (NBOME) prior to acceptance into a postgraduate training program.

Resident physicians provide varying levels of unsupervised patient care within postgraduate training programs and therefore should be required to demonstrate a minimum level of basic medical knowledge prior to entering such training programs. Passage of USMLE Steps 1 and 2 is an appropriate indicator of an individual's preparedness for entering postgraduate training. Step 1 is designed to determine if an examinee can understand and apply important concepts of the basic biomedical sciences with a special emphasis on principles and mechanisms underlying health, disease and modes of therapy. Step 2 focuses on the principles of clinical science that are deemed important for the practice of medicine under supervision in postgraduate training. Medical students who have not demonstrated the preparedness to enter postgraduate training by successful completion of Steps 1 and 2 should continue academic training until they are able to demonstrate this minimum level of cognitive knowledge.

Passage of USMLE Steps 1 and 2 prior to entry into postgraduate training program is a valid discriminator for predicting the completion of training and ultimate licensure. In fact, 67% of physicians who failed to complete successfully either or both USMLE Steps 1 and 2 by their medical school graduation, still had not passed both Steps 1 and 2 within four (4) years following graduation. In order to sit for USMLE Step 3, which a physician must pass to receive a license to practice, passage of Steps 1 and 2 is a prerequisite. Based upon this scenario, one would question if these individuals incapable of passing Steps 1 and 2 will ever achieve licensure. Although the number of physicians disciplined within the first five years of graduation from medical school remains small, the Federation's data disclosed that the cohort of individuals who had not met the requirement of passing Steps 1 and 2 were sanctioned twice as often when compared to individuals who had successfully completed Steps 1 and 2 at the time of their entry into postgraduate training.

The vast majority of resident physicians pass USMLE Steps 1 and 2 prior to entering a postgraduate training program; therefore, only a small subset of potentially unqualified physicians would be affected by this examination requirement. With implementation of computer-based delivery of USMLE in 1999, every medical student will have both convenient access and multiple opportunities to demonstrate his/her ability to pass Steps 1 and 2 prior to graduation. Therefore, concerns regarding a negative affect on the resident matching program should be ameliorated. It should also be noted that international medical graduates are required to complete successfully USMLE Steps 1 and 2 to obtain certification by the Educational Commission for Foreign Medical Graduates (ECFMG), a credential required for entry into U.S. postgraduate training programs.

Given the shrinking availability of health care resources, funding should be reserved for training resident physicians who demonstrate a minimum level of competency necessary to succeed in a postgraduate training program and who have a high probability of obtaining medical licensure through passage of USMLE Steps 1, 2 and 3. This position is further supported by the Pew Commission Federal Policy Taskforce in its report for reforming Federal Graduate Medical Education policy, recommending that teaching facilities be guaranteed reimbursement only for residents with demonstrated competency (through passage of USMLE Steps 1 and 2 or the Comprehensive Osteopathic Medical Licensing Exam Levels 1 and 2).

2. All physicians enrolled in postgraduate training programs shall be subject to medical board regulation and oversight through a mechanism that requires the physician to obtain training permit or limited license expressly designed for such purpose. This mechanism shall also require that program directors report annually to the medical board on all individuals enrolled in their respective programs.

State medical boards are mandated to protect the public safety by ensuring medical services are delivered only by qualified physicians and demonstrate fitness to practice, and therefore medical boards should have jurisdiction over all physicians exercising responsibility for patient care, whether in training or otherwise.

Two-thirds of state medical boards currently have some degree of authority over resident physicians; however, these systems should be strengthened to identify incompetent and/or problematic physicians who may exploit inconsistencies in the current system. The public should be equally and adequately protected in all jurisdictions and therefore, all states should implement mechanisms to require residents to obtain a limited license or training permit. Problem resident physicians should not be immune from disciplinary action for breaches of state medical practice acts and should not be able to move from one program to another and from one jurisdiction to another without coming to the attention of the respective state medical board.

In order for state medical boards to make informed decisions regarding renewal of training permits or limited licenses, it is important for program directors to provide a report to the medical board of physicians recommended for advancement or who have completed their training program. To adequately protect the public, it is also important for program directors to report those few individuals whose behaviors/actions have been of such a nature as to threaten patient welfare and safety, and may warrant further evaluation by the state medical board. It is recognized that many physician disciplinary problems can be traced to early behaviors or occurrences. Early identification of these physicians will allow the medical board to institute safeguards to protect the public while allowing the physician to complete training. It is expected that the need to remove a physician from a training program will, in actuality, be a rare occurrence and only for egregious reasons.

3. All applicants for licensure should have satisfactorily completed a minimum of three years of postgraduate training in an ACGME- or AOA-approved postgraduate training program including completion of PGY3 level training prior to full and unrestricted licensure.

The traditional model of postgraduate training upon which current licensure requirements are based has evolved significantly over the past 25 years. Currently, the curriculum of the senior year of medical school varies widely among institutions and the traditional rotating internship whereby a physician received broad-based exposure to major areas of medical practice, has largely disappeared. According to the ACGME, today there is wide variation in the timing and sequence of the various training elements among the 7000+ residency programs in the United States, and it is therefore impossible for state medical boards to discern, prior to completion of postgraduate training, which applicants for licensure have achieved appropriate training that qualifies them for a full and unrestricted license to practice medicine.

Twenty-five (25) states currently require three (3) years postgraduate training for graduates of foreign medical schools to obtain initial licensure while only one (1) state has the same requirement for graduates of U.S. and Canadian medical schools. The three-year requirement would alleviate concerns of discrimination as related to physician licensure and establish uniform standards for all applicants for licensure.

In order to adequately protect the public, only those physicians deemed qualified to receive full and unrestricted licensure should be allowed to provide unsupervised care to patients, especially critical in the high risk and demanding environment of an emergency setting. Therefore, full and unrestricted licensure should not occur until applicants have successfully completed a postgraduate training program.

Federation of State Medical Boards
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Euless, Texas 76039

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http://www.fsmb.org