Expanding Licensure Portability And Access To Care: Lessons Learned During COVID-19.

Regulatory flexibility by US states and territories during the COVID-19 pandemic rapidly facilitated the practice of medicine across state lines by physicians and other health care professionals, both in person and via telehealth, and greatly expanded access to care. Policy makers and health care leaders at the state and federal levels need to better understand which of these efforts (temporary expedited licenses, licensing waivers, interstate licensure compacts, and data credentialing platforms) worked well, under which circumstances, and how they might complement one another to facilitate more rapid and widespread adoption of measures to improve access to care in times of crisis and beyond. Lessons learned during this global public health crisis should better inform the nation's emergency preparedness efforts ahead of the next calamity.

Regulatory Authorities and Continuing Education Around the World: Adapting to COVID-19.

At a time when the world continues to be gripped by one of the most significant pandemics in history, medical regulators are understanding, more than ever, the value of effective regulation on the provision of health care locally, nationally and across national borders. It has never been more important for regulators to work together, share experiences and information, and strive for regulatory best practice.

Evolution of Clinical Skills Assessment in the USMLE: Looking to the Future After Step 2 CS Discontinuation.

The COVID-19 pandemic interrupted administration of the United States Medical Licensing Examination (USMLE) Step 2 Clinical Skills (CS) exam in March 2020 due to public health concerns. As the scope and magnitude of the pandemic became clearer, the initial plans by the USMLE program's sponsoring organizations (NBME and Federation of State Medical Boards) to resume Step 2 CS in the short-term shifted to long-range plans to relaunch an exam that could harness technology and reduce infection risk. Insights about ongoing changes in undergraduate and graduate medical education and practice environments, coupled with challenges in delivering a transformed examination during a pandemic, led to the January 2021 decision to permanently discontinue Step 2 CS. Despite this, the USMLE program considers assessment of clinical skills to be critically important. The authors believe this decision will facilitate important advances in assessing clinical skills. Factors contributing to the decision included concerns about achieving desired goals within desired time frames; a review of enhancements to clinical skills training and assessment that have occurred since the launch of Step 2 CS in 2004; an opportunity to address safety and health concerns, including those related to examinee stress and wellness during a pandemic; a review of advances in the education, training, practice, and delivery of medicine; and a commitment to pursuing innovative assessments of clinical skills. USMLE program staff continue to seek input from varied stakeholders to shape and prioritize technological and methodological enhancements to guide development of clinical skills assessment. The USMLE program's continued exploration of constructs and methods by which communication skills, clinical reasoning, and physical examination may be better assessed within the remaining components of the exam provides opportunities for examinees, educators, regulators, the public, and other stakeholders to provide input.

Demographic Trends From 2005 to 2015 Among Physicians With Accreditation Council for Graduate Medical Education-Accredited Anesthesiology Training and Active Medical Licenses.

BACKGROUND: A temporary decrease in anesthesiology residency graduates that occurred around the turn of the millennium may have workforce implications. The aims of this study are to describe, between 2005 and 2015, (1) demographic changes in the workforce of physicians trained as anesthesiologists; (2) national and state densities of these physicians, as well as temporal changes in the densities; and (3) retention of medical licenses by mid- and later-career anesthesiologists. METHODS: Using records from the American Board of Anesthesiology and state medical and osteopathic boards, the numbers of licensed physicians aged 30-59 years who had completed Accreditation Council for Graduate Medical Education-accredited anesthesiology residency training were calculated cross-sectionally for 2005, 2010, and 2015. Demographic trends were then described. Census data were used to calculate national and state densities of licensed physicians. Individual longitudinal data were used to describe retention of medical licenses among older physicians. RESULTS: The number of licensed physicians trained as anesthesiologists aged 30-59 years increased from 32,644 in 2005 to 36,543 in 2010 and 36,624 in 2015, representing a national density of 1.10, 1.18, and 1.14 per 10,000 population in those years, respectively. The density of anesthesiologists among states ranged from 0.37 to 3.10 per 10,000 population. The age distribution differed across the years. For example, anesthesiologists aged 40-49 years predominated in 2005 (47%), but by 2015, only 31% of anesthesiologists were aged 40-49 years. The proportion of female anesthesiologists grew from 22% in 2005, to 24% in 2010, and to 28% in 2015, particularly among early-career anesthesiologists. For anesthesiologists with licenses in 2005, the number who still had active licenses in 2015 decreased by 9.6% for those aged 45-49 years, by 14.1% for those aged 50-54 years, and by 19.7% for those aged 55-59 years. CONCLUSIONS: The temporary decrease in anesthesiology residency graduates around the turn of the 21st century decreased the proportion of anesthesiologists who were midcareer as of 2015. This may affect the future availability of senior leaders as well as the future overall workforce in the specialty as older anesthesiologists retire. National efforts to plan for workforce needs should recognize the geographical variability in the distribution of anesthesiologists.

Do Professionalism Lapses in Medical School Predict Problems in Residency and Clinical Practice?

PURPOSE: Recognizing that physicians must exhibit high levels of professionalism, researchers have attempted to identify the precursors of clinicians' professionalism difficulties, typically using retrospective designs that trace sanctioned physicians back to medical school. To better establish relative risk for professionalism lapses in practice, however, this relationship must also be studied prospectively. Therefore, this study investigated the sequelae of medical school professionalism lapses by following students with medical school professionalism problems into residency and practice. METHOD: Beginning in 2014, 108 graduates from Harvard Medical School and Case Western Reserve University School of Medicine who appeared before their schools' review boards between 1993 and 2007 for professionalism-related reasons were identified, as well as 216 controls matched by sex, minority status, and graduation year. Prematriculation information and medical school performance data were collected for both groups. Outcomes for the groups were studied at 2 points in time: ratings by residency directors, and state medical board sanctions and malpractice suits during clinical practice. RESULTS: Compared with controls, students who appeared before their schools' review boards were over 5 times more likely to undergo disciplinary review during residency (16% vs 3%, respectively) and almost 4 times more likely to require remediation or counseling (35% vs 9%, respectively). During clinical practice, 10% of those who had made review board appearances were sued or sanctioned vs 5% of controls. Logistic regression for these outcomes indicated, however, that professional lapses in medical school were not the only, or even the most important, predictor of problems in practice. CONCLUSIONS: Students with professionalism lapses in medical school are significantly more likely to experience professionalism-related problems during residency and practice, although other factors may also play an important predictive role.

Physician Burnout and Barriers to Care on Professional Applications.

We surveyed New York physicians to study their perceptions of reporting requirements related to their own mental health care on professional applications, including whether they were experiencing symptoms of burnout. Over half of the responding physicians reported experiencing symptoms of burnout and these physicians were at increased odds of perceiving a barrier to seeking mental health care if they had to report such care on professional applications and renewals for medical licensure, malpractice, and hospital privileges and credentialing compared to physicians not experiencing symptoms of burnout. As state medical boards, hospitals, and insurers seek information to help assess risks posed by physicians, it is essential to strike an appropriate balance between their duty to protect the public and the physician's right to confidentiality. This balance can be assessed based on the questions that are asked on various professional applications and how information gleaned through physician responses is used. Overly intrusive questions, though well intentioned to protect the public, may run counter to current interpretations of federal law and may inhibit care-seeking among physicians, which is critical to both patient safety and physician health.

Navigating Tumultuous Change in the Medical Profession: The Coalition for Physician Accountability.

Collaboration among the national organizations responsible for self-regulation in medicine in the United States is critical, as achieving the quadruple aim of enhancing the patient experience and improving population health while lowering costs and improving the work life of clinicians and staff is becoming more challenging. The leaders of the national organizations responsible for accreditation, assessment, licensure, and certification recognize this and have come together as the Coalition for Physician Accountability. The coalition, which meets twice per year, was created in 2011 as a discursive space for group discussion and action related to advancing health care, promoting professional accountability, and improving the education, training, and assessment of physicians. The coalition offers a useful avenue for members to seek common ground and develop constructive, thoughtful solutions to common challenges. Its members have endorsed consensus statements about current topics relevant to health care regulation, advanced innovation in medical school curricula, encouraged a plan for single graduate medical education accreditation for physicians holding MD and DO degrees, supported interprofessional education, championed opioid epidemic mitigation strategies, and supported initiatives responsive to physician workforce shortages, including the Interstate Medical Licensure Compact, an expedited pathway by which eligible physicians may be licensed to practice in multiple jurisdictions.

The Relationship Between Board Certification and Disciplinary Actions Against Board-Eligible Family Physicians.

PURPOSE: Lack of specialty board certification has been reported as a significant physician-level predictor of receiving a disciplinary action from a state medical board. This study investigated the association between family physicians receiving a disciplinary action from a state medical board and certification by the American Board of Family Medicine (ABFM). METHOD: Three datasets were merged and a series of logistic regressions were conducted examining the relationship between certification status and disciplinary actions when adjusting for covariates. Data were available from 1976 to 2017. Predictor variables were gender, age, medical training degree type, medical school location, and the severity of the action. RESULTS: Of the family physicians in this sample, 95% (114,454/120,443) had never received any disciplinary action. Having ever been certified was associated with a reduced likelihood of ever receiving an action (odds ratio [OR] = 0.35; 95% confidence interval [CI] = 0.30, 0.40; P < .001), and having held a prior but not current certification at the time of the action was associated with an increase in receiving the most severe type of action (OR = 3.71; 95% CI = 2.24, 6.13; P < .001). CONCLUSIONS: Disciplinary actions are uncommon events. Family physicians who had ever been ABFM certified were less likely to receive an action. The most severe actions were associated with decreased odds of being board certified at the time of the action. Receiving the most severe action type increased the likelihood of physicians holding a prior but not current certification.

The Role and Value of Public Members in Health Care Regulatory Governance.

American medicine has progressively embraced transparency and accountability in professional self-regulation. While public members serving on health care regulatory boards involved with the accreditation, assessment, certification, education, and licensing of physicians provide formal opportunities for voicing public interests, their presence has not been deeply explored. Using 2016 survey and interview data from health care organizations and public members, the authors explore the value and challenges of public members. Public members were often defined as individuals who did not have a background in health care and provided a patient perspective, but in some instances prior health care experience did not automatically exclude these individuals from serving as public members. Public members served on the majority of national health care regulatory boards and constituted an average 9% to 15% of board composition, depending on how rigidly the organizations defined "public member." Public members were valued for their commitment to the priorities and interests of the public, ability to help boards maintain that public focus, and various professional skills they offer to boards. A main challenge that public members faced was their lack of familiarity with and knowledge of the health care field. The authors suggest several considerations for improved public member integration into health care regulatory organizations: clearly defined roles of public members, including evaluating whether or not previous health care experience either contributes or hinders their role within the organization; greater visibility of opportunities for the public to serve on these boards; and potentially a more intensive orientation for public members.

Improving Residency Selection Requires Close Study and Better Understanding of Stakeholder Needs.

The United States Medical Licensing Examination has long been valued by state medical boards as an evidence-based, objective assessment of an individual's progressive readiness for the unsupervised practice of medicine. As a secondary use, it is also valued by residency program directors in resident selection. In response to Chen and colleagues' consideration of changing Step 1 scoring to pass/fail, contextual and germane information is offered in this Invited Commentary, including a discussion of potential consequences, risks, and benefits of such a change. A review of stakeholders involved in the residency application process and their possible reactions to a scoring change precedes a discussion of possible changes to the process-changes that may better address expressed concerns. In addition to pass/fail scoring, these include limiting score releases only to examinees, changing the timing of score releases, increasing the amount and improving the quality of information about residency programs available to applicants, developing additional quantitative measures of applicant characteristics important to residency programs, and developing a rating system for medical school student evaluations. Thoughtful and broad consideration of stakeholders and their concerns, informed by the best evidence available, will be necessary to maximize the potential for improvement and minimize the risk of unintended adverse consequences resulting from any changes to the status quo. An upcoming invitational conference in 2019 that is being organized by several stakeholder organizations is expected to further explore underlying issues and concerns related to these options.

Specialty Certification Status, Performance Ratings, and Disciplinary Actions of Internal Medicine Residents.

PURPOSE: Little is known about the attrition of physicians trained in internal medicine (IM). The authors sought to examine career paths, disciplinary actions, and American Board of Medical Specialties (ABMS) certification status of IM residents. METHOD: Three datasets were combined to study 66,881 residents in Accreditation Council for Graduate Medical Education-accredited IM residency programs nationwide from 1995 to 2004. Group differences (among an American Board of Internal Medicine [ABIM]-certified cohort; an ABMS-certified cohort (but not ABIM-certified); and a noncertified cohort) in IM residency performance ratings, specialty certification status, year of initial IM training, and medical board disciplinary actions were examined. Analyses included chi-square tests, analysis of variance, pairwise comparisons, and logistic regressions. RESULTS: Ninety-five percent of IM residents obtained ABIM certification; 1.6% received ABMS certification in another specialty; 3.4% received no ABMS specialty certification, of which 74.3% have a current medical license; and 66.6% self-reported IM as their primary specialty. During residency, the ABIM cohort performed better than those who never obtained ABIM certification. Disciplinary actions were lowest for the ABIM cohort (1.2%), 2.4% for the ABMS cohort, and highest and more severe for the noncertified cohort (6.0%). CONCLUSIONS: Only 5% of IM residents do not achieve IM certification. IM resident attrition minimally impacts physician supply, though those without certification appear to contribute disproportionately to poor physician performance indicators. Improved tracking of the U.S. physician workforce could aid policy makers in predicting manpower shifts in certain specialty areas, both during and after residency training.