Doctors are among the most trusted professionals in the United States. Yet, apart from an understanding that they undergo rigorous training in medical school and endure exacting residency programs, few of us appreciate the processes through which our doctors are permitted to care for us in the hospital.
In fact, completion of a medical degree and residency are only the beginning. And a medical license does not automatically grant its bearer hospital access.
Licensing
There is no national medical license in the United States. Rather, each state has its own medical board responsible for overseeing the licensing of physicians within its jurisdiction. State medical boards evaluate individual applicants, ensuring that they meet state-specific requirements. These typically include a criminal background check, verification of educational credentials, and documentation of clinical training.
Most states require successful completion of a national licensing exam.
For allopathic physicians holding a medical degree (MD), licensing is generally contingent upon a passing score on the United States Medical Licensing Examination (USMLE), which is jointly owned by the National Board of Medical Examiners (NBME) and the Federation of State Medical Boards (FSMB).
The USMLE is three-step examination which evaluates a physician’s ability to apply medical knowledge and principles to patient care scenarios. The third step of the USMLE, which is typically taken after at least one year of postgraduate training year in a U.S.-accredited graduate medical education program, establishes a candidate’s ability to practice medicine without supervision.
Students completing a Doctor of Osteopathic Medicine (DO) degree must pass the Comprehensive Osteopathic Medical Licensing Examination of the United States (COMLEX-USA) as a requirement for graduation from U.S. osteopathic medical schools. Administered by the National Board of Osteopathic Medical Examiners (NBOME), the three-level exam is designed to assess osteopathic medical knowledge and clinical skills required for the practice of osteopathic medicine.
Passing either the USMLE or COMLEX does not guarantee state licensure. And because neither timelines nor acceptance can be guaranteed, some states specifically caution applicants for medical licensure against making significant professional or personal changes until the process is complete.
The American Medical Association suggests that applicants expect state licensing to take up to two months after the submission of all paperwork. It notes,“Even physicians with uncomplicated histories and complete, accurate applications may experience delays in obtaining a medical license.”
Credentialing
Before a licensed physician can work in a particular hospital, they must be credentialed by the institution’s administration. As the name suggests, credentialing is the process of verifying that a physician is licensed and has the credentials he or she claims to hold.
The Joint Commission requires its accredited organizations to conduct primary source verification of physicians’ credentials. It defines primary source as “(v)erification of an individual practitioner’s reported qualifications by the original source or an approved agent of that source.”
As an example, a credentialing specialist or other member of a hospital’s medical staff services office might call, securely email, or otherwise directly contact a medical school to confirm that the physician in question did, in fact, successfully complete study there. A hospital may also meet primary source standards by contracting with a recognized credentials verification organization.
Credentialing also entails queries to the National Provider Data Bank (NPDB), a “web-based repository of reports containing information on medical malpractice payments and certain adverse actions related to health care practitioners, providers, and suppliers.”[1]
NPDB was established under the Health Quality Improvement Act of 1986 (HCQIA), which also established qualified immunity from civil lawsuits for healthcare providers engaging in specified peer review activities.
NPDB is maintained by the Health Resources and Services Administration (HRSA) of the Department of Health and Human Services. Access to its information is restricted to registered representatives of a strictly defined set of eligible entities, although a provider may request a self-query to review information in their own file.
Federal law requires that hospitals and certain other healthcare entities report professional review actions affecting the clinical privileges of physicians or dentists to the NPDB within 30 days. Reportable actions may include summary suspensions, reductions, or restrictions of privileges, as well as the surrender or self-restriction of privileges by a physician or dentist while under investigation by a review board or in an effort to avoid investigation.
Privileging
After a hospital has confirmed a physician’s credentials, its medical staff can proceed with granting the provider medical privileges. Privileges specify which activities and procedures a physician may perform and are typically specific to their education and medical specialty. An obstetrician, for example, would reasonably be expected to request privileges to “perform breech and multifetal deliveries.” However, their request to undertake orthopedic procedures would likely be denied or invite additional scrutiny and review.
Hospitals typically offer lists of core privileges for individual specialties. These comprise procedures which a provider having completed a residency in the specialty would generally request and generally be qualified to perform without additional training. (An example of core privileges for orthopedics is included here.)
Physicians have the option of indicating which, if any, core privileges they do not want. They may also request additional or special privileges by adding them in a request attached to a core privilege request form or by completing a supplemental privilege request form.
In granting privileges, a hospital may require board certification, board eligibility, or completion of a residency or fellowship in a specialty. For certain privileges, a physician may need to show that they have completed a minimum number of a given procedure within a defined timeframe or may need to agree to proctoring for a specified number of procedures.
For emerging technologies, a physician may need to show that they have completed training with the manufacturer or vendor.
Specialty groups or patient advocacy groups may suggest credentialing or privileging standards. As an example, in 2022 the American College of Radiology, the American Society of Nuclear Cardiology, the Society for Cardiovascular Magnetic Resonance (SCMR), and Society of Nuclear Medicine and Molecular Imaging issued a joint credentialing statement for cardiac positron emission tomography (PET)/magnetic resonance imaging (MRI), which was endorsed by the American Heart Association.
Procedures for granting medical privileges are set forth in each hospital’s bylaws. Generally, privilege requests are reviewed by the chair of the relevant medical department or section and voted upon by the department members or representative committee.
In its Code of Ethics, the American Medical Association emphasizes that “(p)hysicians who are involved in granting, denying, or terminating hospital privileges have an ethical responsibility to be guided by concern for the welfare and best interests of patients” and should not be influenced by the economic or insurance status of a physician’s patient base or the potential competition a newly credentialed provider may pose.
An ongoing process
For all of the effort which goes into the processing of licensing, credentialing, and privileging, none are permanent. Depending upon state statute, physicians are required to renew their medical licenses every one to three years and to support their renewal applications with evidence of continuing medical education.
By law, hospitals must make an NPDB query for each physician on staff every two years. Hospital bylaws are typically written to coincide with this requirement and specify biennial recredentialing and privilege review.
[1] https://www.npdb.hrsa.gov/topNavigation/aboutUs.jsp