Should Medical Licensing Examinations
Be Required for Physician Licensure?

By Melanie R. Margolis

Generally, physician licensure requirements are governed by state medical practice acts, and state medical boards are charged with licensure of physicians, regulation of the practice of medicine, and disciplining violators of the medical practice act. In Texas, for example, the State Board of Medical Examiners (Texas Board) plays this role. A number of bills have been filed in the Texas Legislature this session that would amend the Texas Medical Practice Act, changing the requirements for physician licensure. (See SB 680, its companion HB 2792, HB 1987, HB 3217, and HB 3454).

Two interesting provisions in one of these bills would: (1) allow otherwise qualified graduates of Texas medical schools who have not passed their licensing examinations after five attempts to practice medicine in medically underserved areas; and (2) allow physicians licensed in other states to automatically be entitled to licensure in Texas. Opponents of these measures argue that the medical services of physicians admitted to practice medicine in the state in these ways would be of questionable quality. Proponents would argue that much-needed health care services could be increased for medically underserved populations and the process for licensing out-of-state physicians would be simplified.

The Federation of State Medical Boards (FSMB), which has 69 member boards (including the Texas Board), aspires to improve "the quality, safety and integrity of U.S. health care by promoting high standards for physician licensure and practice, and assisting state medical boards collectively and individually in the regulation of medical practice and in their role of public protection." The FSMB Special Committee on Uniform Standards and Procedures (Uniform Standards Committee) made licensure recommendations which were adopted by the FSMB in May 1998. See Maintaining State-based Medical Licensure and Discipline: A Blueprint for Uniform and Effective Regulation of the Medical Profession (Blueprint).

According to Blueprint, "licensure requirements are generally consistent across the FSMB's membership. Virtually all boards require an applicant to show evidence of having graduated from an accredited medical school, to have passed an acceptable examination sequence and to have successfully completed at least one year" of approved postgraduate training. (Emphasis added).

In 1997, the FSMB approved as policy A Guide to the Essentials of a Modern Medical Practice Act (Essentials). Essentials was published "[t]o serve as a guide to those states that may adopt new medical practice acts or may amend existing laws; and.[t]o encourage the development and use of consistent standards, language, definitions and tools by boards responsible for physician regulation." FSMB devotes an entire section of Essentials to examinations, recommending specifically that "[n]o person should receive a license to practice medicine in the jurisdiction unless he or she has passed an examination or examinations satisfactory to the Board."

FSMB recommends that "[a]ll applicants for postgraduate training shall have satisfactorily competed 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." Blueprint. If satisfactory completion of examination is required for medical school graduates in postgraduate training, FSMB would argue that it should be required for medical school graduates working in medically underserved areas.

Essentials addresses limited licensure for postgraduate training. The holder of such a limited license should be restricted to practice only under appropriate supervision and at locations acceptable to the state board. It seems to follow that an otherwise qualified medical school graduate who has not passed his or her examinations should not be accorded greater licensure rights than a medical school graduate engaging in postgraduate training. To allow a medical doctor who has not passed examination(s) to practice medicine, especially in situations in which he or she is likely not to have adequate supervision, would be viewed as unacceptable to licensing bodies.

The FSMB recommends in Essentials that medical practice acts contain only certain physician licensure exceptions, as follows: (1) medical students in approved medical schools; (2) persons providing services in an emergency without fee; (3) medical officers of the U.S. armed forces, the U.S. Public Health Service, or the Veterans Administration of the U.S.; (4) dentists, nurses, optometrists, podiatrists, psychologists and others practicing the healing arts in accordance with applicable law; (5) persons practicing the religious tenets or ministering to the sick by mental or spiritual means; (6) persons treating a family member with a lawful domestic or family remedy; and (7) persons fully licensed to practice medicine in another jurisdiction in the U.S. who briefly render emergency or critical medical services at the lawful direction of a medical institution or federal agency that assumes full responsibility for such services and is approved by a state medical board. Note that the FSMB does not recommend an exception for those providing medical treatment for the medically underserved.

With regard to out-of-state physicians, in its recommendation for endorsement of unlicensed applicants, the FSMB provides in Essentials that an applicant for license by endorsement should have: (1) complied with all requirements for licensure other than examination; (2) passed a medical licensure examination in another U.S. jurisdiction or Canada, "provided that the state board determines that the examination was equivalent to its own." (Emphasis added). The FSMB, therefore, does not recommend licensing out-of-state physicians based solely on their status as licensed physicians elsewhere. Instead, a state board should look at the examination given in the other jurisdiction and decide whether it was equivalent to its own.