In the
United States, medical licenses are usually granted by individual states. Only those with medical degrees from schools listed in the
World Directory of Medical Schools are permitted to apply for medical licensure.
Board certification is a separate process. The federal government does not grant licenses. A physician practicing in a federal facility, federal prison, US Military, and/or an Indigenous Reservation may have a license from any state, not just the one they are residing in. The practice of "tele-medicine" has made it common for physicians to consult or interpret images and information from a distant location. Some states have special licensure for this. The licensure process for most physicians takes between three and six months, due to the extensive background checks, educational, training, and historical primary source verifications.
History The
Tenth Amendment to the Constitution became the underpinning for the entire medical licensing system. Following several years of discussion and debate, the states' ratification of this amendment as part of the
Bill of Rights concluded on December 15, 1791. It explicitly avowed that powers not granted to the federal government, nor prohibited to the states by the Constitution. The Tenth Amendment remains a living codification of states rights and is routinely cited by state medical boards today to justify the authority delegated to them by their state legislatures. The
American Medical Association when formed in 1847, proposed that the state legislate medicine (rather than each of the different medical schools). Horowitz argues that this suggestion was made in order to gain greater control over medical education. The majority of physicians had M.D. degrees earned in American medical schools. The rest were mostly either homeopaths or eclectics. Homeopaths were trained in a pseudoscientific system known as
homeopathy that had been developed by
Samuel Hahnemann. Eclectics physicians also attended medical schools, but their practice mixed mainstream medicine with
Thomsonsianism, a system of
herbalism. Each of these groups was organized into both national and state medical societies across the United States. In 1889,
Dent v. West Virginia, the U.S. Supreme Court for the first time upheld a state physician licensing law. A practitioner with insufficient credentials to obtain a medical license sued West Virginia, claiming a violation of his rights under the
Due Process Clause of the
Fourteenth Amendment. The Supreme Court upheld the statute noting that, while each citizen had a right to follow any lawful calling, they were subject to reasonable state restrictions. Because of the nature of medical training, the large amount of knowledge required, and the life-and-death circumstances with which physicians dealt, patients needed to rely on the assurance of a license requiring physicians to meet a minimum set of standards. In 1956, the
Federation of State Medical Boards released "A Guide to the Essentials of a Modern Medical Practice Act." The report distilled a series of recommendations that addressed five core areas: the definition of the practice of medicine; eligibility standards for licensure; licensing examinations; licensure endorsement; and the bases for probation, suspension, or revocation of a license. Today, physicians are amongst the most highly regulated professionals with detailed criteria for licensing established by medical boards in each state, however, lack of discretionary action against physician misconduct by state medical boards has been criticized in recent years for their failure to discipline physicians, despite several consumer concerns and complaints.
Criticism According to a 1979 article in the
Journal of Libertarian Studies, the enactment of U.S. state medical licensing laws in the late 1800s was for the primary purpose of reducing competition and allowing physicians to make more money. The added benefit of public safety made restrictive licensure laws more appealing to both physicians and legislators. Infrequently mentioned in the literature, is that the "public safety" that is created by reducing the number of practitioners only extends to the patients who receive medical care. Thus, the overall effect is more expensive and higher-quality medical care for fewer patients. Beyond the more general criticisms of
occupational licensing that licensing increases costs and fails to improve quality, licensing in the medical profession specifically has been criticized as failing to enforce the standard practices they are charged with enforcing. In 1986, Inspector General at the
United States Department of Health and Human Services said that medical boards took "strikingly few disciplinary actions" for physician misconduct. There have been a number of cases involving patient deaths where physicians only had their licenses removed years after multiple wrongful patient deaths had happened. State medical boards have increased the number of disciplinary actions against physicians since the 1980s. Also, it has been said that because hospitals have had more legal burden placed on them in recent decades, they have more of an incentive to require that their physicians be competent. Thus, the process whereby physicians are reviewed and licensed by the state medical board results in some duplicate evaluations. The physician is evaluated both in the licensure process and then again by the hospital for the purpose of credentialing and granting hospital privileges. Laws in some states prohibit interstate telemedicine without a license to practice in the state where the patient is located. According to the
Cato institute, this reduces access to care.
Patient protection State medical boards cannot assure a high standard of care, they do not review physicians on a regular basis, nor do they evaluate clinicians at the point of care. It is provider liability that results in oversight that protects consumers, and even that is imperfect. Before they employ or associate with individual physicians, via credentialing and privileging, providers confirm the training, knowledge and skills needed to take on relevant tasks. They review any sanctions and malpractice claims. There are cases where physician liability has been stripped by federal regulations, with adverse impacts, as on an Indian Reservation. Medical professional liability insurance companies deny problems physicians malpractice insurance or limit their practice. == References ==