According to the AMA, “physician re-entry” is defined as “a return to clinical practice in the discipline in which one has been trained or certified following an extended period of clinical inactivity not resulting from discipline or impairment.” Re-entry is distinct from “remediation,” during which a physician may need time away from practice or a period of monitoring because of issues identified in his/her practice. Re-entry is also different from “re-training,” in which a physician is not in active practice while he/she trains for another specialty. Re-entry refers to the path for physicians who voluntarily leave the practice of medicine, allow their licenses to lapse or change to inactive or exempt status, and then wish to re-active their licenses to return to practice.
The issue of physician re-entry has been discussed for decades. Given the looming physician shortages, as well as the increasing number of women in medicine who may take time off during their careers to raise children or care for other family members, the time would appear to be ripe for a more focused discussion, re-engaging the multiple interested parties, to make this process more obvious, easier, and more streamlined. Having an organized path to re-entry would also address the increasing public demand for physician accountability. It is important in discussing physician re-entry to remember that state medical licensure is not the same as hospital credentialing. Most states don’t require clinical activity to maintain an active license; however, credentialing and liability coverage typically do.
Based on a survey undertaken by the AMA, 49 state medical boards have policy or regulations describing re-entry as attempting to obtain an active license after an “extended period of clinical inactivity.” These policies or regulations include a range of time, from 1 to 10 years (mean 2.8 years), after which the board “may” (and usually do) recommend or mandate evaluation before granting a license to practice medicine. What defines “clinical inactivity,” or more specifically, what is the “active practice of medicine,” referred to in many regulations? For most, if not all state medical boards, the active practice of medicine is typically not thought to include administration, research, or teaching and implies direct patient care.
Currently, the process for re-entry is cumbersome. Most states medical boards have regulations concerning re-entry that indicate a mandated or discretionary assessment of competence. These assessment programs are spread around the country. Assessments typically include cognitive function screening, simulated patient cases that are specific to the area of training or intended area of practice, simulated patient chart reviews, clinical interviews, and possibly written testing. This process is also expensive, with estimates of up to $20,000. This includes not only the fees of the for-profit assessment programs, but also the costs of re-locating and travel and any recommended educational programs. Although re-entry programs associated with academic health centers are not-for-profit, there are still costs associated with attending these programs. There are currently no scholarships or public funding available to cover these costs. After completing a re-entry program, there is no guarantee of licensure or employment to then earn the money needed to offset this financial investment. Cost, along with the issues of identifying appropriate proctors and the impact of a limited license, have been cited as the primary concerns of those who have contemplated, but not completed, a re-entry program.
If issues are identified during the assessment process, a re-entry plan is developed. This may include additional CME or other education. In addition, supervised clinical experiences or independent practice with a preceptor may be recommended as a result of the assessment or if there are concerns about clinical skills, given the duration of time out of practice. The length of this period of monitoring is variable and may be 6 to 12 months. This monitoring requirement is noted as a stipulation for licensure and, unfortunately, may be viewed by some states as a restricted or limited license. This can make participation in some insurance contracts or obtaining hospital privileges challenging. To address this, a few states have enacted the category of “re-entry license.” For example, Kansas enacted legislation, effective July 1, 2015 (KSA 65-2809(j)), that established such a licensure designation that was non-disciplinary and intended for those seeking reinstatements of an active license or those applying for a designation change from inactive or exempt licensure. Considering that the goal of licensure is public protection, this license can be renewed annually for up to 2 years, to assure that all patient care and/or knowledge base issues are adequately addressed.
Although proctoring or monitoring prior to entering practice may be required, this may not be easy to actualize. Community physicians may be concerned about liability coverage for their mentees or may not have the time or experience to adequately assess knowledge and skills, provide remediation, and evaluate the impact of such remediation. There is also concern that proctoring physicians may see the re-entering physician as a potential future partner, providing opportunities for bias in any evaluations. Having re-entering physicians engage in “mini-residencies” is another model that has been utilized. However, since these physicians do not have an active license, they typically aren’t reimbursed by third party payers, and there continues to be limited funding for graduate medical training of any kind. In addition, concerns have been raised about the potential impact of having these additional learners on the educational experiences of residents and fellows in training. However, Varjavand et al, in surveying ob/gyn residents at a single program, found that having re-entering physicians participating in their program as additional learners at worst at no impact and frequently provided additional viewpoints and enhanced their education.
If you are contemplating taking time away from your practice, plan this as carefully as everything else you do in your life.
- Check the website of your state’s medical board to find out how long you can be out of the active practice of medicine before needing to undergo an evaluation to regain an active license.
- If at all possible, maintain an active license. Although this means time and money spent on CME, this is significantly easier, and less expensive, than later needing to participate in an assessment program.
- Maintain your clinical skills. This may be a day or 2 every week or 2 at a free clinic, supervising residents in a local training program, or helping cover call at a local practice or emergency department. While this takes away from the time that you were planning on spending with your family, the reason you may have taken time away in the first place, this is less cumbersome that attempting to identify someone to act later on as a practice monitor or preceptor if there is concern whether you have maintained your clinical skills.
- If you decide that you don’t have time for any clinical activity, check with your state medical society and/or state medical board to see if your state has a re-entry category of licensure and speak with someone at either of those groups to find out what the specific requirements are in your state. If your state has no such category, re-think your opinion that you don’t have time for clinical activity. A limitation on your license, even if this monitoring so that you can to return to practicing medicine, will not only lead to the issues with insurance companies and hospitals but will need to be reported whenever you apply for a license. Also, if your state doesn’t have a re-entry category of licensure, that would also be a good time to speak with your state medical society to find out why and to see if that can be addressed.
As the face of women in medicine, AMWA has an active interest and investment in this process and is positioned to take the lead in this endeavor. AMWA has been active in facilitating discussions of all interested parties, including physician advocacy organizations, the Federation of State Medical Boards, policy makers, re-entry programs, national testing organizations, and the public in addressing this important public health priority. If you have questions, please contact me at firstname.lastname@example.org.
Kim Templeton, MD, FAMWA, FAOA
Immediate Past-President, AMWA
Past President and Member, Kansas State Board of Healing Arts