I left practice 25 years ago when I saw portents of clinical practice as it exists today: impersonal, with electronic records and assembly-line labor heralding the movement to institutional employment over private practice.
But it was also my genuine interest in population health and pharmaceutical medicine that propelled me into a nonclinical career. The jobs I chose in this millennium were with health insurance and pharmaceutical companies, where medical licenses were optional, at least in pharma. Nevertheless, I maintained an active license in Pennsylvania, where I worked most of my career.
I moved to Florida about ten years ago, so I applied for a medical license thinking my Pennsylvania license would be reciprocal in the sunshine state. I was dead wrong. In order to become licensed in Florida, I had to demonstrate active participation in medical practice for at least two of the previous four years. I hadn’t seen a patient in more than ten years. Storm clouds threatened my employment in the sunshine.
I completed the licensing application, including my practice history, and sent it off to Tallahassee. I received a letter summoning me to appear before the medical board to discuss my clinical experience. Scores of physicians attended the same meeting – the medical board’s credentialing committee meeting. Most of the physicians were accompanied by their attorneys, pleading to have their licenses reinstated following revocation for criminal offenses. I came alone.
“Dr. Lazarus,” a board member asked me, “how long has it been since you last practiced medicine?” I answered that it was over a decade since I had seen a patient face-to-face. The audience gasped (everyone was privy to everyone else’s testimony). In my defense, I explained that I had no intention of practicing medicine in Florida, that I intended to work in industry, and that I maintained a license in Pennsylvania as well as a medical school faculty appointment with a well-established record of presentations and publications.
The medical board was not impressed. They said my faculty appointment was an adjunct appointment and that it did not involve medical practice or supervising residents. They did not consider my job in industry tantamount to the practice of medicine, even though I went into detail about how my work included clinical elements related to patient safety and treatment efficacy.
I sensed I was losing the battle. I made one last attempt to persuade the board. I told them it was ironic that physicians like me working in nonclinical positions might be forced to go without a license, yet state medical boards could discipline them for egregious behavior, which meant that licensing boards did, at times, provide nontraditional physicians a license and consider them engaged in practice. “You can’t have it both ways,” I argued.
The Florida medical board was not swayed by my logic. “Dr. Lazarus,” the committee member continued, “if you want a Florida medical license, you’ll have to retake your specialty boards [in psychiatry] to prove your competence.”
“But I passed my boards in 1986 and was granted lifetime certification,” I countered. The medical board, however, wanted additional assurance beyond lifetime certification, a faculty appointment, and achievements and accomplishments outlined in my 30-page curriculum vitae. So, I took a weekend crash course in New York to prepare for the boards and passed them again. My Florida license was issued a year after my initial application.
Surprisingly, retaking and passing the boards triggered maintenance of certification (MOC) requirements. The organization that issued my lifetime certification, The American Board of Psychiatry and Neurology (ABPN), was unwilling to waive the MOC requirement. I tried enlightening them – explaining that retaking the boards was a condition of obtaining a Florida medical license. Still, ABPN was unmoved by my circumstances. They said if I failed to maintain certification, my official record would read “certified, MOC not met.” Huh?
I asked ABPN, “What if I had taken my psych boards on my own initiative, just to prove myself I still have what it takes to be a psychiatrist?” I received the same answer – “although you will be considered to have lifetime certification, you are still required to complete MOC requirements and retake board examinations every ten years.”
How ridiculous! Pony up more money? For what? A process that is burdensome, irrelevant, not evidence-based, and misaligned with adult learning theory – not to mention that the very act of renewing a medical license requires continuing medical education (CME) courses that maintain one’s medical acumen.
The majority of states, like Florida, require that physicians be engaged in active practice to receive a medical license. For trainees, this is usually not an issue. But for physicians in nonclinical positions who move from one state to another, and for physicians on the move who are active in settings that routinely do not involve direct patient care – for example, preventive medicine physicians and physicians who are primarily in research, academic, or administrative roles – they are at odds with the often narrow definitions of “clinical practice” and “active medical practice” defined by state legislatures and medical boards.
Nonclinical physicians tend to become lumped with physicians who have a gap in practice due to illness, sabbaticals, motherhood/fatherhood, disenfranchisement, and other personal reasons. To regain or reactivate their medical licenses, they are at the mercy of state licensing boards’ “re-entry” requirements – extensive CME, refresher training, mentorship programs, mini-residencies, passing clinical assessments and board exams, etc. From that perspective, only being ordered to retake my boards was a gift.
The takeaway from this story is to maintain your medical license even if it is not a requirement for your current job or intended line of work. However, if you envision moving to another state and have not seen patients within two years – find out what the requirements are for licensure in that state before you move there or accept a new position. Some states may be willing to relegate you to a second-tier license, but accepting a license with a lesser status (eg, “administrative,” “retired,” or “faculty”) only postpones an inquisition should you decide to return to traditional practice.
Arthur Lazarus is a psychiatrist.
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