Summary of Report to Congress

Process by which International Medical Graduates are Licensed to Practice in the United States

A Report of the Council on Graduate Medical Licensure WorkGroup

September 1995

Executive Summary

This report to Congress was mandated by Section 307 of Public Law 102-408, the Health Professions Education Extension Amendments of 1992. Congress, concerned that the medical licensure policies and practices of state medical boards might be discriminatory with respect to graduates of foreign medical schools ("international medical graduates"), mandated that three sets of issues be addressed:

1. Credentials verification - The statute called for a review of a private credentials verification system then being operated by the American Medical Association. Recommendations were to be developed for the establishment of nondiscriminatory policies and practices for the operation of the system and for the establishment and operation of any similar system.

2. Licensure policies and practices of State medical boards - The policies and practices of the individual states, including any relevant laws, with respect to the licensing of international medical graduates (IMGs) and domestic medical graduates (USMGs) were to be examined.

3. Medical licensure application processing times and percentage of applications approved - The statute called for an empirical study of the average length of time required for states to process the licensure applications of lMGs and USMGs respectively, and the respective percentages of applications approved. Any significant differences between the two groups of applicants with respect to these variables were to be highlighted and the reasons for the differences identified.

FINDINGS AND REC0MMENDATIONS

Credentials Verification

1. The time required to verify the credentials of physicians applying for licenses remains a critical element in creating differences in the application process between international and domestic medical graduates.

2. AMA's decision to phase out the AMA/NCVS® was based on its determination that the resources needed to maintain a high-quality service that met subscriber needs and State medical board requirements necessitated either a larger subscription base or higher fees. Of the nine States included in the survey of medical boards, three (Arizona, Louisiana, and Ohio) utilized the service; one State (Texas) would have negotiated a contract for the service had it not been discontinued. Reasons offered by the other States for not using the service fell into three broad categories:

    

   cost

    

   perceived system limitations, and

    

   statutory or regulatory constraints

3. Asked to identify the organization they felt would be "most appropriate" to operate a successor system to the AMA/NCVS®, every State that replied chose the Federation of State Medical Boards (FSMB). Two States chose the Educational Commission for Foreign Medical Graduates (ECFMG) as well, and one State chose the AIM (Administrators in Medicine).

4. The FSMB recently completed a feasibility study, approved by its Board of Directors, which concluded that a substantial majority of State boards had an interest in the Federation's establishing and operating such a service. Many boards stated that they would seek to make the service mandatory within their jurisdiction.

RECOMMENDATIONS:

1. A national credentials verification system is urgently needed to assist State medical boards in verifying the credentials of IMGs and USMGs applying for initial licensure (the process by which physicians apply for the first time to practice in the United States) as well as licensure by endorsement (the process by which physicians licensed in one State apply to practice in another). The documentation requirements of the system should be uniform and nondiscriminatory as between IMGs and USMGs.

2. The Federation of State Medical Boards (FSMB) is encouraged to proceed with its efforts to develop a national credentials verification system to be used for both initial and endorsement licensure. In addition:
   FSMB is encouraged to pursue these efforts in cooperation with ECFMG, and IMG organizations and other entities.

   Federal and private sector technical and financial assistance should be explored during the development and implementation of the system.

Licensure Policies and Practices of State Medical Boards

1. Policy differences regarding the lMG and USMG licensure application process continue to exist. The survey of nine State medical boards and a review of the literature revealed some of those differences. While the survey of medical boards was insufficient in scope to reach conclusions regarding the entire population of licensing jurisdictions, the literature review produced a number of substantive findings, briefly summarized below:
   Documentation-It is more difficult for lMGs to obtain, and for State medical boards to verify, the credentials documentation required for licensure than it is for USMGS, which may account for some of the delay in processing applications. The difficulty arises from the absence of a formal accreditation process that would certify the quality of medical education in medical schools outside the United States and Canada.

   Examination requirements - Following years of different examination requirements for IMGs as opposed to USMGs, a single medical examination - the United States Medical Licensure Examination, or USMLE - is now accepted by all 54 licensing jurisdictions. This advance, implemented incrementally between 1992 and 1994, levels the playing field for IMGs who have not yet taken an examination. It does not, however, address the problem faced by an IMG licensed in one state based on an examination taken prior to the availability of the USMLE, who then seeks an endorsement license in another state which does not recognize the earlier examination.

   Graduate medical education - As of 1995, 34 licensing jurisdictions require more years of graduate medical education for IMGs than for USMGs. Of the 28 jurisdictions that require three years of graduate training for the initial licensure of IMGs, only one requires three years of such training for USMGs, two require two years, while the remaining twenty-five require only one year of graduate training for USMGs.

2. Despite advances in some respects, considerable diversity exists among State medical boards with respect to both the primary and additional requirements for licensure imposed on IMGs. Many boards insist on documenting the authenticity of medical school diplomas and other credentials. In some instances, the State law authorizing the medical board mandates such documentation.

3. A major step toward uniform requirements was taken with the adoption of the USMLE as the examination required for licensure in all States. The Workgroup anticipates additional progress toward the achievement of uniform licensure requirements.

RECOMMENDATIONS:

1. Maximum uniformity among States in licensure requirements is a recommended goal. While the Workgroup acknowledges the need for State medical boards to address the licensure issues mandated by their respective legislative bodies, it is recommended that the Federal government work with the FSMB to encourage States to seek greater uniformity of requirements.

2. An effective, expedient licensure process is needed for both IMGs and USMGs. In the interest of facilitating licensure processing and portability, States should be encouraged to share and retain information concerning the credentials of foreign medical schools. Applicants should not be asked to produce original documentation on aspects of their medical education that have already been documented in other States or in recent years within the same State.

Medical Licensure Application Processing Times and Percentage of Applications Approved

The limited number of States surveyed (nine) precluded reaching definitive conclusions regarding the nation as a whole. The data nonetheless yielded several important insights:

Processing times

If "processing time" is defined as the number of days between the date on which an application for licensure is received by the State medical board and the date on which a licensure decision is reached, differences in the application policies and/or practices of several States (California, Louisiana, and Texas) tended to mask the true IMG-USMG differences in those States. Additional information on these differences, which ranged in both directions, may be found in the body of the report (section 2.3).

In five of the other six States surveyed, IMG - USMG comparisons could reasonably be made. In each of those States, forty case histories, divided evenly between IMGs and USMGs, were studied, with the following results: average processing times tended to be longer for IMGs, compared to USMGs, with respect to initial licensure but not with respect to endorsement licensure. In four of the States, the average time required to process initial licensure applications from IMGs exceeded that for USMGs by amounts ranging from 24 to 35 days; in the fifth State, there was no difference. In States where there was a difference, the average processing time for IMGs ranged from 27 to 75 percent greater than that for USMGs. These differences, however, do not necessarily convey differential treatment; some of the difference may result from the greater mailing times required to solicit and receive original documentation from foreign medical schools. The differences in processing time for endorsement applications showed no pattern in one direction or the other.

Recommendation:

Consideration should be given to reconvening a medical licensure workgroup or similar group at an appropriate time in the future (e.g., in three years) to assess continued progress in the area of uniform credentials requirements and "nondiscriminatory" treatment of international medical graduates.