Physician burnout (And how some hospitals are helping with it)

If you’re feeling emotionally exhausted, detached or dissatisfied, you may be experiencing burnout. But the prognosis is good—hospitals and medical schools are finding many new ways to tackle the problem.

By Debbie Swanson | Feature Articles | Winter 2017


“Practicing medicine is my true calling. I enjoy it immensely,” says Crystal Moore, M.D., Ph.D., a successful anatomic and clinical pathologist at Hampton Veterans Affairs Medical Center in Hampton, Virginia. “It’s not just what I do; it’s who I am.”

But Moore admits things weren’t always easy. When completing her residency at Duke University, she became irritable, had difficulty sleeping and lost her joy. Difficulties at home added to the drain: Her mother and sister were terminally ill, and she was raising two young sons while dealing with a failing marriage.

“I did what many doctors do: grit my teeth and bear it. Keep moving, no matter how worn out you are by life or work,” Moore recalls. Once she successfully completed her residency, she acknowledged the problem. “I had nothing left in the tank. I didn’t look for full-time employment. I was emotionally, physically and psychologically spent.”

A visit to her doctor helped—she was able to begin the process of sorting through the issues weighing her down. Looking back, she admits it was “ridiculous” to have gone so long without seeking help.

Dr Crystal Moore

Physicians facing burnout should seek intervention early. Says Crystal Moore, M.D., Ph.D.: “What I know most of all is Physician, heal thyself.” · Photo by Fowler Studios

“Being a physician is hard work on many levels. Add life and stir, and you may have a recipe for the perfect storm,” she reflects. “What I know most of all is Physician, heal thyself.”

In any profession, it’s normal to feel stressed, tired, even completely fed up at times. But when bad days become the norm and good days are few, it’s time to take action. Career burnout is a real problem—one particularly prevalent among health care workers. In addition to mental and physical suffering, studies show that physician burnout can negatively affect the care you give your patients, causing increased medical errors, riskier prescribing patterns and lower patient adherence to disease management plans.

But burnout doesn’t have to be a career-ender. There are ways to prevent—and recover from—the negative feelings of burnout.

Part 1: The background

The term “burnout” was the brainchild of psychologist Herbert Freudenberger, who popularized it in the 1970s as a way to collectively describe the consequences that can arise in people employed in high-stress careers with set ideals. He noted that burnout was particularly prevalent among workers in helping professions, such as health care.

In the 1980s, researchers Christina Maslach and Susan E. Jackson, with the University of California, Berkeley, extensively studied burnout in the service industry and devised the Maslach Burnout Inventory, a measurement tool used to assess symptoms. The team defined the syndrome around three constructs:

  • Emotional exhaustion: feeling emotionally drained and exhausted.
  • Depersonalization: negative or detached feelings toward your recipients of care (patients, in physicians’ case).
  • Reduced personal accomplishment: negatively evaluating yourself and feeling unsatisfied with job performance and achievements.

Not all three must be equally prevalent to classify the overall problem as burnout. Some research suggests intensity of symptoms varies by gender: Men tend to experience more depersonalization, while women tend to suffer more from emotional exhaustion.

Today the problem is not only common among medical practitioners but also on the rise. According to the 2015 Medscape Physician Lifestyle Report, 46 percent of all physician respondents reported burnout, an increase of more than 16 percent from the 2013 survey. Critical care showed the highest rates at 53 percent, while emergency medicine was second at 52 percent. Both internists and family physicians also showed a significant rise, from 43 percent in 2013 to 50 percent in 2015.

Ingredients may vary. Demanding hours, challenging cases, pressure from clients or colleagues—the factors that lead to burnout are many, and vary greatly with each individual. Aside from professional stressors, personal problems like marital or relationship conflicts, child care difficulties or financial concerns further stir up the waters. Everyone processes problems differently, so it’s impossible to point to specific conditions leading to the outcome of burnout.

For physicians, the changing landscape of health care can be a trigger. With more physicians today opting to work for a hospital or health care system—75 percent in 2011 as compared to 25 percent in 2002—management difficulties are more common. According to a study by Jackson Healthcare, a significant gap exists between what executives perceive, and what physicians report, as their level of engagement and alignment. Although most physicians responded they were “proud” to be associated with their employers, they also cited negatives: lack of trust in leadership, lack of involvement in decision-making and lack of recognition for their expertise.

What to do. If you’ve noticed your job satisfaction waning, a good first step is to visit your own doctor. Underlying medical conditions, a nutritional imbalance or health issues may be exacerbating your negative feelings. Counseling is also beneficial to learn some coping strategies and recognize possible adjustments to make in your lifestyle. Resources may be available through your employer or health insurance company. (You’ll find further tips in the sidebar “Stop! Don’t leave your current job just yet.”)

Part 2: What hospitals are doing to help

Increasingly, hospitals and practice groups are taking steps to address burnout, recognizing that the alternative—losing skilled employees—is costly. Many have implemented preemptive initiatives to foster unity, address common problems and teach prevention and coping skills. Medical schools are also developing curriculums to teach students ways to manage stress throughout their careers.

The following are some examples of such programs across the country.

California Pacific Medical Center: balanced scheduling. Historically, physicians are known for working long hours spanning consecutive days. But a work-focused lifestyle has been waning in popularity as awareness of the need for balance has become more universal. At California Pacific Medical Center in San Francisco, a group of about 30 hospitalists came together to adopt a scheduling system that would support a more balanced lifestyle.

“We implemented this system about 10 years ago, realizing that the current system wouldn’t be sustainable. Many physicians had young families, and working frequent, entire weekends interferes with that,” says medical director Rob Taylor, M.D.

The group advocated for and implemented a system that schedules higher numbers of physicians during the week and in return requires physicians to work fewer weekends. “We wanted to assign greater value to off-hour shifts as well as weekends. The weekends we do work are busier as a result,” Taylor adds.

Taylor says he and the group as a whole have enjoyed this approach to scheduling. “It eliminates stress. And if a physician needs to take time off, knowing that we have coverage makes it that much easier,” he adds.

Aravind Mani, M.D., a hospitalist in the group, agrees that the balanced clinical schedule helps keep stress at bay. “I have the opportunity to make requests that accommodate my personal time, vacations and other needs.”

Cleveland Clinic: coming together for enrichment and learning. At the Cleveland Clinic, a mandatory training program not only strengthens providers’ ability to communicate with patients but also instills a sense of unity.

Kathleen Neuendorf, M.D.

At the Cleveland Clinic, one training program helps providers manage their clinical encounters, minimizing stress and saving time. “A common reaction we’ll hear from the attendees is relief,” says Kathleen Neuendorf, M.D. · Photo by Full Bloom Photography

The eight-hour program, called “R.E.D.E. to Communicate: Foundations of Healthcare Communication” (pronounced “ready”), teaches practical, realistic communication skills, giving participants valuable tips on how to manage their clinical encounters.

“It’s something that many providers struggle with silently,” says Kathleen Neuendorf, M.D., medical director of the Center for Excellence in Healthcare Communication at the Cleveland Clinic, which runs the program. “A common reaction we’ll hear from the attendees is relief—knowing they’re not the only one having difficulty with a certain type of patient encounter or conversation.”

By enhancing basic communication skills, physicians minimize stress and save time. For example, one tactic covered is sharing an agenda early in patient encounters. “You go into an encounter knowing what you’re going to do: talk, do an exam, discuss labs. Making your patient aware of this agenda in the first few minutes of the visit benefits both the patient and the provider,” explains Neuendorf.

Other skills include making empathetic statements and dealing with patient emotions. In addition to the mandatory basic class, which covers situations common to all providers, there are also optional, half-day classes that focus on specific specialties and patient populations.

But beyond just gaining communication skills, Neuendorf adds that the class is a chance for physicians to get away from daily demands, connect with one another and realize that others share similar difficulties.

“We do it in a place where it isn’t easy for a provider to run back to their desk to do some quick work,” Neuendorf says. “It’s in a quiet setting, to encourage them to take a step away from their work.”

In research done by the Office of Patient Experience, communication skills training has been shown to improve patient satisfaction scores, promote physician empathy and self-efficacy and reduce physician burnout.

University of Wisconsin School of Medicine and Public Health: learning mindfulness. As part of a one-year study on creating a culture of mindfulness in medicine, Cindy Haq, M.D., attended a seminar designed to teach mindfulness to medical professionals. Upon completion, she was optimistic that this was a strategy beneficial to her fellow physicians.

“It was a fabulous opportunity for deeper learning and to learn how to teach strategies to deal with the daily pressure and stress common to a physician,” recalls Haq, who was one of five participants in the study through the Integrative Medicine Program in the Department of Family Medicine and Community Health in the University of Wisconsin School of Medicine and Public Health.

A family physician and professor at the University of Wisconsin, Haq soon began sharing her findings with her peers and began incorporating talk about compassion training in the Training in Urban Medicine and Public Health (TRIUMPH) classes she was teaching. These classes prepare students to work in urban, medically underserved populations.

“It’s easy to become engulfed in problems. You can’t solve them on your own; they’re bigger than you,” says Haq, adding that she’s seen many well-intentioned students become overwhelmed.

The session was so well-received by her students that she made it a weekly event. Haq looked at the training as a tool she could give to students, “a way to stay in the game without becoming overwhelmed—something hopefully that these students could carry through their careers.”

Mindfulness—the practice of training your mind to stay in the present—may be a new concept to many, but its roots extend to Hinduism as early as 1500 B.C. Today the practice is a widely recognized tool for stress reduction and wellness.

“Mindfulness training is a great way to help maintain peace of mind, clarity, and not let the mind run away with itself. It teaches you to recognize your thoughts, and maintain calmness of mind in the face of chaos and confusion,” says Haq.

After the one-year study, all five of the primary care leaders who participated reported personal value from the training, with one describing it as “life-changing.” Each went on to foster a variety of mindfulness activities to benefit colleagues, medical students and patients.

Carolinas HealthCare System: tapping into external resources. At the Carolinas HealthCare System, a group of senior administrators and physician leaders recently came together to develop ways to improve wellness and decrease burnout among physicians and advanced care practitioners. This physician wellness committee, now in its second year, has launched a number of different efforts, such as creating a website of resources and encouraging regular meetings to come together to discuss difficult cases.

One of the more popular efforts involves lectures delivered by Wayne M. Sotile, Ph.D., from the Sotile Center for Resilience in Davidson, North Carolina.

“It’s not a system-wide effort yet, but he’s met with multiple departments,” says wellness committee member David Fisher, M.D., director of neonatology at Levine Children’s Hospital, part of the Carolinas network. “We’ve experienced education of our faculty and staff through recurrent seminars and lectures, which have all been well-attended.”

Sotile, who has worked in the area of resilience for more than 30 years, calls burnout “a new, old problem. It’s now getting a lot of attention, but it’s been a problem forever.”

Sotile’s seminars present evidence-based strategies and tactics to curb burnout in a hospital setting. “I’ll deliver digestible bites of information, let them think about it a while, then come back again to reinforce it and do more training,” he says.

While he says he can help physicians cultivate coping skills, he also points out that they usually can’t do it alone. “I help them take responsibility for what they can change—their own attitudes and coping skills. But change needs to be accompanied by some practice redesign, some engagement from the organizations.”

Feedback so far has been positive, from both staff and administrators.

Becoming a physician is the culmination of years of studying and working hard. Like any mental or physical condition, no one chooses to become overcome by the problem of burnout. Fortunately, its effects can be reversible; as Moore found, burnout can be a temporary interruption from a satisfying, fulfilling career in medicine. Taking action early is the best way to regain joy in the career you’ve worked hard to attain.



Two of the best medical apps of 2016 (and one just for fun)

This issue’s app reviews include a prescription saver, a daily aspirin decision tool and a vein seeker not yet ready for clinical use.

By Iltifat Husain, M.D., founder of | Tech Notes | Winter 2017


In this edition of Tech Notes, we’ll cover GoodRx’s new app for physicians; a critical app for primary care physicians related to daily aspirin use; and an app that helps you see veins using just your iPhone’s camera. Each of these medical apps is free to download and easy to use.

Aspirin Guide Simplifies the aspirin decision-making process

Aspirin Guide

Price: Free iTunes: Android:

For any physician or provider who has to determine whether or not to start a patient on daily aspirin for primary prevention of cardiovascular disease, Aspirin Guide is the most important app you will use.

It’s one of the best medical apps released in 2016 and is a must-have for primary care physicians and cardiologists. It’s from researchers at Harvard Medical School and helps health providers decide which patients are candidates for the use of low-dose aspirin.

The decision to start patients on aspirin is much easier for secondary prevention of cardiovascular disease; it gets complicated when it comes to primary prevention due to the consequences that can arise, such as serious bleeding events.

The U.S. Preventive Services Task Force (USPSTF) gives various grades of recommendation for use of aspirin in primary prevention for cardiovascular disease and colorectal cancer. The determination isn’t based just on age, but also various medical calculators the USPSTF wants providers to use.

Aspirin Guide simplifies the decision-making process. The app can be used at the point of care with patients. It does all the backend work of calculating risk scores based on your various inputs. Aspirin Guide also can email the results to your patients so that they can see why there was a decision to start on daily aspirin or not.

The app is available for iPhones and Android and is available as a web app as well.

Key ways to use this app. Use this app to determine if your patients should be on daily aspirin use for primary prevention of atherosclerotic cardiovascular disease (ASCVD). Use it to calculate 10-year cardiovascular disease risk score, and use it to email a summary of the decision-making process.

GoodRx For Doctors Helps your patients save money on prescriptions


Price: Free iTunes: Android:

GoodRx has been one of the most downloaded medical apps in the App Store for the last few years. It provides coupons for prescription medications and can help patients save money on prescription drugs.

Patients or physicians are able to input a particular drug and dosing and then get a list of pharmacies that offer the lowest price.

GoodRx is particularly useful for patients who do not have insurance, but it can also help those who have insurance save on prescription drugs.

For example, clindamycin can cost my patients paying out of pocket more than $60, but using GoodRx, I can get them the prescription for less than $15.

GoodRx partners with a pharmacy benefit manger (PBM) in order to get lower prices of prescription medications. PBMs are able to negotiate discounts with pharmacies, and they earn a transaction fee for sending customers to a pharmacy.

GoodRx recently released a physician-centric version of their app, GoodRx For Doctors. The app makes GoodRx much easier to use with patients. In the past, I would have had to use GoodRx on a desktop, search for a drug, and print out the coupon for my patient. With GoodRx For Doctors, I’m able to save my favorite prescriptions more easily, and I can easily send my patients a text or email of the coupon right from my phone. When the patient gets the coupon via text on their phone or in their email, it doesn’t convey my personal information.

Key ways to use this app. Use this app if you have patients without insurance or the drug isn’t on the $4 Walmart list. It’s best for patients who have smartphones (otherwise, just print the actual coupon for your patient in clinic). Use this app to look up information on the drug prescribing; there is a decent drug monograph available.

VeinSeek Identifies vein location with an iPhone

Vein Seek

Price: Free iTunes: Android: Not available

Unlike the other two serious apps mentioned for clinicians, VeinSeek is a fun app that only health professionals will get a kick out of. It’s important to note this app should not be used for medical purposes or on any patients.

VeinSeek is a live video processing app that uses your iPhone’s camera and layers of algorithms to show veins on your arm. “Vein seeking” devices have been around for awhile—they use infrared light to show veins. But VeinSeek doesn’t require any add-ons or attachments; it simply uses algorithms to help distinguish veins.

This app is nowhere near ready for primetime, but it shows the power of what a smartphone camera can do when connected to smart software.

Key ways to use this app. As mentioned, you definitely can’t use this app for any type of patient care or any type of medical treatment. But it’s a good proof of concept and an example of how live video processing apps have potential to be used in the medical setting in the future.

Iltifat Husain, M.D., is the editor in chief and founder of, the leading physician publication on digital medicine, and an assistant professor of emergency medicine at Wake Forest University School of Medicine.



Your nose, your tail, and what’s in between

A malpractice insurance primer for job-seeking physicians

By Colin Nabity | Financial Fitness | Winter 2017


They may sound a little off-the-wall, but the terms used for medical malpractice insurance were designed to help professionals easily remember which types of coverage relates to which period of time. You only need one—nose or tail—and the main difference relates to whether the coverage for prior acts is purchased from your new insurance provider or your old one.

Your nose: Purchased from the new carrier

Nose coverage refers to the period that you were covered under a claims-made malpractice policy that was terminated at the same time a new policy with a different carrier was issued. With this coverage, incidents that occurred during the nose period (your prior policy), but were not reported until the new policy started, are covered by the new carrier.

This coverage is needed since the typical professional liability policy is issued on a claims-made rather than an “occurrence” basis. This means that coverage must be available when the claim is reported instead of when the claim occurred. When it comes to medical malpractice, it is not unusual for an incident to be discovered years after a procedure took place.

If you decide to change insurance carriers, your new carrier is going to require a list of all procedures performed before the requested issue date of the new policy. They will ask for loss runs from the prior carrier to determine if any prior claims are open or have been closed. If you want your new carrier to offer coverage for your nose period, be prepared to provide a lot of information about your practice during that time.

Your tail: Purchased from the old carrier

Tail coverage is important because claims may be reported long after a procedure or service. The tail option in your liability policy allows you to extend coverage from your old carrier for a number of years when you cancel your insurance because you are closing your practice or switching employers.

When applying for coverage, it is critical to determine what tail coverage options are available, especially when it comes to the cost of coverage and the time limit available. Your tail coverage provides protection if there is an incident related to a procedure or service you performed during the policy period, but a claim was not filed until after the policy period. Tail coverage is typically required when you are closing or selling your practice.

Example 1. You have decided to retire and close your practice that has been in business for 30 years and has been insured the entire time. However, you are still liable for all procedures performed during those 30 years (depending on your state’s statute of limitations) and must remain covered for as long as possible after you close your practice. With the appropriate tail coverage, any claim brought for past procedures will be covered under the last carrier that provided your malpractice insurance.

Example 2. You have decided to retire and sell your practice. The buyer has requested that you provide tail coverage for three years so that your patients can be transitioned into the new practice. Even if the buyer doesn’t require the tail coverage, you should ask for tail coverage just in case you are named in a malpractice suit so you will have defense costs coverage available.

Lapse in coverage

A lapse is a period when you continue to provide services without being insured under a professional liability (malpractice) policy. This is not only financially dangerous to your practice, but will also cause problems when you do get a policy in place. Since the insurance carriers have no way of properly underwriting for the period of lapsed coverage, they will typically not offer coverage for that period, or they will apply a significant surcharge.

Know if your defense costs are inside or outside

Your malpractice coverage will pay for defense costs, settlement costs and judgments awarded by a court. It is important to know whether your defense costs are inside or outside the policy limits.

Inside the policy limits: Defense costs inside the policy limits are deducted from your policy limit first and can significantly reduce the amount left over to pay judgments and settlements. These costs include attorney’s fees and general court costs that occur before a judgment or settlement is reached. You should consider that your defense can be the costliest part of a malpractice claim.

Outside the policy limits: With defense costs paid outside the policy limit, the significant cost of defending your case will not impact the limit available for settlement costs and judgments.

Your malpractice insurance can stand between a claim and financial devastation. It’s extremely important to make an informed decision before committing to a purchase rather than at the time of a claim.

Colin Nabity is the founder and CEO of LeverageRx, an online financial help desk for physicians, dentists and other medical professionals looking for personal financial guidance.



Congress advances laws for mental health and addiction treatment

Republicans and Democrats joined together to promote best practices and more options for delivery of mental health care and addiction treatment.

By Jeff Atkinson | Reform Recap | Winter 2017


Although Republicans and Democrats in Congress have gridlocked on many issues, they have managed to agree on new laws regarding mental health treatment and addiction treatment.

By a vote of 422-2, the House of Representatives passed the “Helping Families in Mental Health Crisis Act of 2016” (H.R. 2646). The act now moves on to the Senate.

Emphasis on best practices

The act calls for development of “evidence-based best practices and service delivery models” for providing mental health care. Areas of emphasis include coordination with physical health care, coordination with the corrections system, suicide prevention, and care for children and the homeless.

Several laws, including the Affordable Care Act, provide for parity between physical health care and mental health care. The difficulty in implementation can be in the details. The new mental health act directs regulators in multiple cabinet departments to develop more “illustrative examples of nonquantitative treatment limitations on mental health and substance use disorder benefits” as well as examples of medical and surgical benefits. Regulators will seek to make more clear to providers and patients the circumstances in which various inpatient and outpatient services are appropriate and should be covered.

Cost savings

Another goal of the act is cost savings. Lawmakers believe there have been unnecessary costs in delivery of personal care and home health care services under Medicaid. The act requires development and use of an “electronic visit verification system”—a more reliable method for making sure services are delivered and for tracking the amount of time spent on such services.

The details of this program will be developed between now and 2019 with input from stakeholders. Beginning in 2019, if a state does not have an electronic visit verification system for personal services, the federal government will reduce payments to the state for the state’s Medicaid program. For home health care services, the penalties for noncompliance will begin in 2023. The penalties begin at .25 percent and increase over a four-year period to 1 percent.

Changes in privacy rules

Drafters of the act are concerned that persons with serious mental illness often lack capacity to make sound decisions regarding their care, and that as a result their health suffers.

One of the findings in the act is that people with serious mental illnesses “die 7 to 24 years earlier than their age cohorts primarily because of complications from their chronic physical illness and failure to seek or maintain treatment resulting from emotional and cognitive impairments.”

The act directs the Department of Health and Human Services to amend regulations under the Health Insurance Portability and Accountability Act (HIPAA) in order “to permit health care professionals to communicate, when necessary, with responsible known caregivers of such persons, the limited, appropriate protected health information of such persons in order to facilitate treatment.”

In addition, the regulations are likely to permit providers to have limited communications with law enforcement to help determine when a person should be admitted for mental health treatment instead of being incarcerated. As with the regulations about the electronic visit verification system, there will be an opportunity for input by stakeholders and the public before the new privacy regulations are finalized.

When Congress wants to give added attention to an issue, one of its techniques is to make adjustments to the command structure of the department that is handling the issue. The mental health act creates a new high-level position in the Department of Health and Human Services: “Assistant Secretary for Mental Health and Substance Abuse.” There also will be a new “Deputy Assistant Secretary.” The act authorizes a variety of task forces to assist with implementation and directs that the department make periodic reports to Congress about progress on mental health issues.

Addiction and recovery act

In July, Congress, with strong bipartisan support, passed the “Comprehensive Addiction and Recovery Act of 2016” (S. 524). President Obama signed the bill into law (Public Act 114-198).


Statistics on mental health and drug abuse

The act is designed to update best practices for pain management and prescription of pain medication, particularly opioids. The new law will fund multiple initiatives, including research, alternatives to opioids, and more treatment facilities. The act has specific programs for treatment of veterans, prisoners and pregnant women.

The new law also provides funding for programs to increase availability of opioid overdose reversal drugs such as Naloxone. In order to make addiction treatment more available, the list of practitioners authorized to dispense or prescribe narcotic drugs for maintenance or detoxification is expanded. The authorized prescribers include licensed nurse practitioners and physician assistants, provided they have had proper training. If state law requires oversight of non-physicians, supervision or collaboration still may be required.

In 2016, the Centers for Disease Control and Prevention issued guidelines for the use of opioids for chronic pain other than active cancer treatment and end-of-life care.

Funding for the Addiction and Recovery Act was a source of tension. The Obama administration wanted $1.1 billion. Republicans wanted about half that amount. When the bill passed the Senate in July, the level of funding was not completely certain. The bill said the new programs were authorized, but the actual dollar amount won’t be set until an appropriations bill is passed later in the year.

In a year with high levels of political conflict, it was refreshing to have two health care acts receive bipartisan support. As the new Congress convenes in 2017, we’ll see how long the cooperation continues.

Jeff Atkinson teaches health care law at DePaul University College of Law in Chicago.



You’ve got the degree and the training. How about the license?

Here’s what you need to know to get licensed and credentialed.

By Kevin Caldwell | Legal Matters | Winter 2017


The basis for medical licensure in any state or jurisdiction today is that state’s Medical Practice Act (MPA). In every state, an MPA is the statutory provision for establishing a state medical board, setting standards and qualifications for licensing physicians, and establishing a mechanism for disciplining licensees who have engaged in unprofessional conduct.

In the U.S., there are 70 medical licensing boards: 36 states with a composite board (licensing both M.D. and D.O. physicians), 14 states with separate allopathic and osteopathic boards, and boards for the jurisdictions of the District of Columbia, Guam, Puerto Rico, the Virgin Islands and the Commonwealth of the Northern Mariana Islands. (A complete listing of all medical licensing boards in the U.S. and its territories, including contact information, is available on the Federation of State Medical Boards (FSMB) website.)

Most physicians’ first interaction with a state medical board will occur during residency. The majority of state medical boards (47) issue some form of limited license or training license to physicians in a residency training program within their state. In some instances, this license is issued to the institution based upon a roster of physicians who are enrolled in good standing in the program. A resident license or limited license usually restricts physicians to supervised practice within the confines of a specific institution.

Although the trend in medicine has moved increasingly toward specialization, state boards issue a license to practice medicine as a physician and surgeon. They do not issue licenses limited to the specific focus, orientation or specialty of a physician’s practice.

In general, a state medical board will issue a license based on a physician meeting requirements in three general areas:

  • Undergraduate medical education;
  • Graduate medical education; and
  • Successful completion of a national licensing exam.

State medical boards classify applicants for licensure, in part, by the location of the med school program they completed as part of their undergraduate medical education. Most MPAs draw a distinction between physicians who graduated from med school programs in the U.S. or Canada and international medical graduates (IMGs), or physicians who graduated from med schools outside the U.S. and Canada.

All state medical boards require a minimum of one year of training in a program accredited by the Accreditation Council for Graduate Medical Education (ACGME) or the American Osteopathic Association (AOA), although many require more than one year. Some boards also recognize training through programs approved outside the U.S., such as those approved by the Royal College of Physicians and Surgeons of Canada.

Fifty years ago, virtually every state developed and administered its own exam for licensure. Today there are two national exams used for initial licensure: the United States Medical Licensing Examination (USMLE) and the Comprehensive Osteopathic Medical Licensing Examination (COMLEX-USA). Both are administered as multi-step exams at various points in the prospective physician’s career. Both exams are primarily cognitive tests but have included clinical skills components since 2004. More information on these exam programs is available at and


Credentialing is the process state medical boards use to verify an applicant’s credentials. This involves collecting and evaluating credentials earned through education, training and experience. Through direct-source verification and attestations from education and training facilities, state medical boards determine whether a physician is eligible for state licensure and prepared to practice medicine without supervision in that jurisdiction.

Credentialing for state licensure is different than credentialing for hospital privileges or managed care. State credentialing focuses more on the educational curriculum and successful matriculation from undergraduate school to medical school and medical school to residency. Credentialing for hospital privileges or managed care focuses more on a physician’s specific abilities. Hospitals and managed care plans grant privileges to perform specific treatments. State credentialing, on the other hand, is for the purpose of granting a license for the general, undifferentiated practice of medicine.

Both credentialing requirements and how credentials are obtained are unique to each licensing jurisdiction. State medical boards do not adhere to a single national standard for verifying credentials. Physicians will need to familiarize themselves with the requirements of the specific state medical board(s) where they plan to seek licensure. For example, there are currently 14 boards that require applicants to use the FSMB’s Federation Credentials Verification Services (FCVS): Kentucky, Louisiana, Maine (Medical), Nevada (Osteopathic), New Hampshire, New York, North Carolina, Ohio, Rhode Island, South Carolina, Utah (Medical), Utah (Osteopathic), Wyoming and the Virgin Islands.

The FSMB developed the FCVS in 1996 to assist state medical boards in credentialing. Currently all state medical boards, with the exception of Puerto Rico, accept the documents and collection methods of the FCVS to satisfy their particular requirements.

Preparing yourself for Licensing and Credentialing

The pathway from medical student to licensed physician in the U.S. involves many different organizations. To help guide physicians, the FSMB has created an interactive document called “Pathway to Medical Practice in the U.S.” It graphically represents the pathway to licensure and is available for download on the FSMB’s website.

Kevin Caldwell is the Federation of State Medical Board’s senior director of ancillary services, serving as a liaison between the FSMB and its 70 member medical boards. He played a pivotal role in establishing FCVS as one of the nation’s preeminent providers of physician credentialing services.




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