Medical Licensure: It Is Time to Eliminate Practice Borders Within the United States

At this time of a national health emergency caused by the novel coronavirus 2019 (COVID-19) pandemic, indeed a global health crisis, we are reminded of the oath we took as physicians. We dedicated our lives to the most noble of all missions, saving lives and selflessly helping a fellow human in the time of utmost need. No matter what specialty or career path we take, it is always that “patients come first.”

The ability to practice medicine is yet, as it should be, a privilege. Physicians are entrusted with human lives. It is, therefore, appropriate that medical education, training, and the ability to practice are closely scrutinized and highly regulated. Medical schools and residency programs have to maintain accreditations mandated by national standards.1, 2, 3, 4 In addition, all physicians have to pass the 3-step US Medical Licensing Examination (USMLE), which is a prerequisite for obtaining a state-issued medical license to practice medicine in the United States.⁵

What is puzzling and defies logic, however, is that securing a license to practice medicine in one state does not allow for practicing the same type of medicine in another state in the same country. This contradicts the fact that accreditations and standards for medical education and training are regulated at the national level. Are patients living in this country different when they cross state lines? Does the human anatomy or physiology change when crossing the Mississippi River from Missouri to Illinois or driving across the George Washington Bridge from New York to New Jersey, for example? Does a physician really need 4 medical licenses from Arizona, Colorado, New Mexico, and Utah to treat patients separated by the lines of the Four Corners Monument? Or is lupus (a disease I treat) different if a patient wakes up in an Eastern or a Western time zone?

The status quo of restrictions imposed on the practice of medicine by state medical licensure does not make sense and needlessly puts a tremendous pressure on the ability of physicians to do what they do best—take care of patients. Arguably, the current model of medical licensure in the United States restricts patients’ access to care. A physician who is entrusted to practice medicine in one state should be entrusted to do the same all over the United States. The requirement that licensed physicians go through a redundant application process for another state medical license is counterproductive and entails significant effort, time, and resources that are better invested in taking care of patients. There is no value in contacting medical schools and residency training programs to verify the medical degree and training records when a physician is already licensed and practicing in good standing in another state. This laborious verification process has been already performed by the state where the physician is currently licensed. Do state medical boards not trust one another, or is there a different motivation to keep this illogical bureaucratic process in place?

I realize there are significant financial incentives that come to medical licensing boards from the initial license application fees and maintenance fees, and I am not suggesting completely eliminating these sources of financial revenue. A possible solution is to require state medical boards, by a federal mandate, to recognize medical licenses issued by any of the states or territories within the country. Physicians will continue to be required to hold a medical license in good standing to practice medicine. However, this license can be issued from any state regardless of where the physician practices in the United States. Maintenance of a good standing license to practice medicine will be through the original state that issued that license, thus keeping the financial revenue from licensure fees to that state. Indeed, this is exactly the case for the Veterans Affairs (VA) health system, the Indian Health Service, the clinical practice within the National Institutes of Health (NIH), and in military hospitals and clinics around the country. A medical license issued by any state allows physicians to practice in any health facility affiliated with these aforementioned health systems. Patient care is and should not be different if patients are military personnel, receive care at the Indian Health Service, visit the National of Institutes of Health clinics, see their physician at a VA facility, or none of these. So why not make this borderless medical licensure model a rule rather than an exception? Millions of Americans receive care at VA, Indian Health Serivce, or military medical facilities.

An alternative approach is for state medical boards to recognize medical licenses issued by any other state in the country and then use that as the sole basis for issuing a medical license by their own medical boards. If that system was to be adopted, then maintenance of such a license can continue to be issued by the state where a physician lives or wishes to practice, and therefore, this entails no loss of revenue to state medical licensing boards. State medical licensing boards will freely exchange all information relevant to any investigation, disciplinary actions, or license status of any physician.

We should all advocate to extend the ability of physicians to practice and remove these artificial interstate restrictions that serve little if any good to the general public. I suggest that the waiver issued under the Emergency Declaration Act by the US Department of Health and Human Services on March 13, 2020, for the “Requirements that physicians or other health care professionals hold licenses in the State in which they provide services, if they have an equivalent license from another State (and are not affirmatively barred from practice in that State or any State a part of which is included in the emergency area)”⁶ be expanded and extended indefinitely.