Pulse
Reentry Problems
Physicians who temporarily step away from practice may find it’s not easy to go back.
After developing reflex sympathetic dystrophy following foot surgery eight years ago, James Ecker, M.D., thought he was finished practicing medicine. Ecker, who had served as director of radiation oncology at North Memorial Medical Center in Robbinsdale, was told the painful condition was progressive and that he would likely end up in a wheelchair.
Then something unexpected happened. Ecker’s pain subsided unexplainably. Five years after leaving medicine, he felt able to practice again. “I kept missing the work,” he recalls of his time away.
Licensure and Competence
Determining whether a physician who has voluntarily stepped away from clinical practice is competent to return is one piece of a larger issue medical licensure boards are grappling with: whether licensure truly reflects competence.
Linda Van Etta, M.D., president of the Minnesota Board of Medical Practice and an infectious disease specialist at St. Luke’s Hospital in Duluth, has been working with the Federation of State Medical Boards on licensure and competency. She says the interest in competency grew out of the Institute of Medicine’s To Err is Human report, which questioned whether states set the bar for licensure high enough. Van Etta explains that in some states, all a physician has to do to renew their license is send in their money; in others, they must engage in some form of continuing medical education. In Minnesota, physicians must earn 25 credits a year and submit proof to the board every three years.
But is taking part in CME enough to assure ongoing competence? “More and more hospital systems, clinics, and payers are requiring board certification,” Van Etta says. Certification is awarded through the American Board of Medical Specialities’ (ABMS) 24 constituent boards, which represent all the allopathic specialties and subspecialties. Some boards have in the past awarded “lifetime” certificates; others grant or are moving to a “time-limited” certificate, in which physicians must complete learning modules and pass a secured exam every seven to 10 years.
In Minnesota, approximately 70 percent of physicians are board-certified. Van Etta says most, like herself, have lifetime certificates. She explains that the ABMS would like to tie maintenance of certification to maintenance of licensure in order to do away with the lifetime certificates. “But there’s no data right now to show that board recertification in any way translates to good patient outcomes or improved care,” she says.
Van Etta says she’s been encouraging the federation to instead look at the Canadian model, which requires physicians to take part in educational activities but doesn’t require them to pass a secured exam that may not be a good indicator of their clinical skills.
Van Etta believes that if state licensing boards do start tying maintenance of certification in its current form to maintenance of licensure, “it has the capacity to create the greatest physician shortage ever in the United States.”—K.K.
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But Ecker had let his medical license lapse. In order to get it reinstated after being away from clinical practice for so long, he needed to prove to the state Board of Medical Practice that he was still competent to care for patients (see Reinstating a License). “It was obvious to me that I wanted to practice at the same high level that I had. I owed it to my patients,” he says. “But how do you go about doing that?”
With no help available at the time for physicians who had been away from practice and wished to reenter the workforce, Ecker had to be creative. After contacting nearly 15 radiation oncology residency programs about fellowships, Northwestern University in Chicago agreed to take him on as a “visiting professor” for nearly three months. During that time, he attended seminars and presentations, took part in resident functions—charting rounds and doing new patient presentations, and even mentored a resident who was struggling. “It was a wonderful intellectual period,” he recalls.
At the end, his mentors wrote letters saying they felt he was ready to resume practice.
When Ecker went before the Minnesota Board of Medical Practice’s licensure committee three years ago to make his case for reinstatement in order to do locum tenens work, the physicians who heard his case were impressed with the curriculum he had put together to refresh his skills. “The licensure committee had no problem at all welcoming him back to the active practice community,” recalls Rebecca Hafner-Fogarty, M.D., who chairs the committee.
But not all physicians who’ve voluntarily taken time out come before the licensure committee so well-prepared—or even aware that they may have to prove that their skills are still adequate. Hafner-Fogarty says physicians have become “quite hostile” when the committee has recommended they undergo an assessment to find out if their skills and knowledge are current.
Although there’s little national or state data about the number of physicians who take time out from clinical practice, Hafner-Fogarty says the committee has encountered more and more over the last four years who want to return after taking a break to care for their own health, raise families, attend to elders, return to school, or just recharge. She considers the physicians who let their license expire “the tip of the iceberg.” “They’re the ones we know about,” she says. “There’s a much larger group who maintain their license but don’t engage in practice for a variety of reasons, then choose to go back into practice.”
Getting Back in the Saddle
The fact that states such as Minnesota are facing a projected shortage of primary care physicians has brought the issue of helping physicians return to practice to the attention of state licensing boards and national organizations that are looking for creative ways to bring more practitioners to the field. (An Arizona study of reentering physicians found that nearly half were in primary care specialties.) The American Academy of Pediatrics has been leading an effort to identify and break down barriers to reentering clinical practice. The American Medical Association, American Academy of Family Physicians, American Board of Medical Specialties, and Federation of State Medical Boards (FSMB) are among a number of organizations participating in a national work group dealing with the issue. The question they’re wrestling with: How can a state licensing board know whether a physician who has voluntarily stepped away from clinical practice is qualified to return?
“Medical boards are obligated to assure the public that a physician is competent. When physicians who have been away from clinical practice for a period of time want to return to practice, medical boards will want to know how the physicians skills and knowledge have declined over that period of time so that they can make reasonable judgments about the physician’s competence,” says Carol Clothier, vice president of physician competence initiatives for the FSMB, which is working on developing guidelines for state licensing agencies.
Currently, about a dozen states require physicians who have been out of practice for two years or longer to have their knowledge and skills assessed formally, according to Clothier. But is two years a meaningful timeframe? “Two years for a psychiatrist is very different from two years for a cardiovascular surgeon,” says Linda
Van Etta, M.D., president of the Minnesota Board of Medical Practice and chair of a task force on continuing competency and maintenance of licensure that has been discussing reentry and other licensure issues since August of 2006.
In Minnesota, there are no strict guidelines about what a physician needs to do to reenter practice. “If they’ve been away for more that two years, we strongly urge them to consider having a skills assessment, especially if they don’t come to us with a plan [for how they’re going to refresh their skills],” says Hafner-Fogarty.
Only seven organizations in the United States do comprehensive assessments of physician competence, Clothier says. Even fewer retraining programs exist, and many of them are designed for remediation rather than clinical refreshers.
Although Hafner-Fogarty says the Board of Medical Practice can help physicians find courses on topics such as pharmacology, beyond that, they’re on their own to figure out ways to brush up their clinical skills. She says convincing residency programs to take on reentering physicians for brief periods isn’t easy because technically the physicians aren’t residents, so the institution can’t bill the federal government for the care they provide. Also, as Ecker found out, having an expired license made it impossible to qualify for a fellowship. “I was in Catch-22 land,” he recalls. “How do I improve myself to get a license when I need a license in order to improve myself?”
The University of Minnesota hopes to develop a reentry program for physicians that would assess their skills and offer them a clinical experience tailored to their needs and specialty. “If they were a family physician who wanted to go back to practicing in a clinic but not a hospital, we would design a course that would involve supervised patient care in a clinic,” says Louis Ling, M.D., associate dean for graduate medical education, who is leading the effort.
One of the programs they’re looking at as a model is the Interinstitutional Physician Training Program at Oregon Health and Science University in Portland, which is regarded as the “gold standard” for helping physicians reenter practice. Physicians who participate go through an assessment, are mentored by physicians in their specialty, participate in rounds and patient presentations, and undergo a formal written and oral skills assessment and evaluation.
“If we can help keep these physicians in the workforce or return them to the workforce, it’s much more cost-
effective than … educating a new physician,” Hafner-Fogarty says.
Reinstating a License
In Minnesota, physicians must renew their license annually. If a physician skips two renewal cycles, the license is cancelled, and he or she would have to reapply to get it reinstated. Rob Leach, executive director of the Minnesota Board of Medical Practice, says that involves submitting an application and paying $196.
Minnesota currently has no statute or rule stating that a physician must go through a skills evaluation or retraining after being away from clinical practice for a certain period of time. “But generally, if they have not had any clinical practice for more than three or four years, we’d be looking at some kind of retraining,” he says.—K.K.
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Planning Ahead
For now, the Minnesota Board of Medical Practice isn’t proposing any changes to the way it evaluates physicians who wish to return to practice. According to Van Etta, they’re waiting to see what sort of recommendations the FSMB makes on this as well as broader competency and licensure issues (see Licensure and Competence).
Clothier says she envisions state boards moving toward more individualized assessments that would consider the type of work the physician wishes to do, their work history, the quality of care they provided when they were in practice, and what they’ve been doing while they were away from practice. “Have they been keeping up with their CME? Volunteering at free clinics? Also, is the physician a surgeon or an internal medicine physician? That will make a difference,” she says. Clothier hopes to see recommendations on reentry presented to the FSMB House of Delegates in 2009.
In the meantime, Van Etta says physicians who are thinking about taking time off need to understand that the conditions of licensure in Minnesota could change before they decide to return and that they need to be proactive in planning their break. She says physicians may wish to consider scaling back their workload—perhaps working one day a week or job-sharing—rather than leaving practice altogether. They might also think about keeping their license current, which requires earning 25 CME credits a year and submitting proof to the Board of Medical Practice every three years. “Right now, in Minnesota, if you maintain your CME and your license, we have no idea if you’re out of practice,” she says. “That may be good or bad, but it’s something people need to think about before they step out.”—Kim Kiser