Doctors (and Nurses) Without Borders: Rethinking Licensure

Sometimes emergencies teach us things about how the world should be even in normal times.

On August 28th, 2005, a dear friend called me in a panic. He had been rushed to Mississippi as part of an advance team to help set up emergency communications and computing centers in anticipation of Hurricane Katrina. But his crew had been pulled into the most urgent agenda: setting up medical triage centers. He wanted to know what the rules were about doctors practicing medicine during a hurricane. “We’ve got victims already showing up and a crew of docs with us from Stockton, California, but they are afraid to help because they aren’t allowed to practice medicine in Mississippi.” Ten hours and dozens of phone calls later, he and the crew finally decided, “Hell, we’re just going to help people, and if someone wants to put us in jail for it, so be it.”

On August 31st, Health and Human Services Secretary Mike Leavitt provided relief to hundreds of nurses and doctors who had rushed to the Gulf Coast to help care for Katrina victims, using the Public Health Service Act to waive laws that required clinicians hold licenses in all states in which they practice. This was retroactively effective in Louisiana, Mississippi, Alabama, Florida, and eventually Texas as displaced citizens were housed there following the storm.

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The history of–and motives for–our current licensure rules in our country are troubling to me. Today, state licensure boards grant a license for the general, undifferentiated practice of medicine, with the need for doctors and nurses to re-up every one to three years depending on the state. And as we talk about “pay for performance” or “pay for quality” in healthcare reform, I suspect the responsibilities and burdens of state licensing boards will only increase. (For more details, take a look at the American Medical Association guide for doctors on how to move between states.)

So many experts have given me so many different explanations over the past few weeks of interviews I have done on this topic that I am even more confused than when I started. Under the promise of anonymity, an expert physician on the topic of licensure recently admitted to me: “There are really two reasons we continue this terrible way of doing things: first, there is a multi billion dollar industry for doing licensure in all 50 states that doesn’t want their bread and butter taken away. Second, the docs don’t want to give up control of their business model, so they’d rather fight any battles that encroach on their turf in each of 50 states rather than risk losing one legal battle in the federal courts.” I don’t want to believe that these cynical answers are true. But I don’t currently have a better explanation for why things are still the way they are.

In the year 2009, are we being asked to believe that the differences between the medical school education and experiences of a doctor in North and South Dakota are so significant that we need different licensing/credentialing mechanisms between the two states? While the social scientist in me readily admits that cultural, spiritual, and socio-economic differences may require training in different bed-side manner and communications approaches for various communities across the country, I have to believe that the standards of education and care are uniform enough to no longer warrant this age old, state-by-state tradition.

It is time to explore nationalizing the licensure of all doctors and nurses. If we are going to achieve the kind of cost-saving care coordination required for the 21st century, we need borderless care within the United States. Healthcare needs to follow the patient wherever they find themselves in need. Unfortunately, I hear almost no one talking about this issue. Instead, we are holding to “the way it has always been done,” which is preventing innovative care models from emerging and producing borderline care that is too expensive, bureaucratic, and even potentially harmful to patients.

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Several years ago, one of my Intel colleagues was doing ethnographic fieldwork of healthcare workers out in remote parts of eastern Washington and Oregon. One day, he ran into a problem. The only ambulance in town had taken a patient with congestive heart failure on a day-long 400-mile journey to Portland for his routine pacemaker checkup. The border town of Ontario is only 45 miles away from Boise, Idaho, but the physician wasn’t licensed to practice medicine in both states so sent his patient to the “nearest” urban center.

Later that day, an elderly woman on a ranch outside of Ontario fell and hit her head after a major stroke occurred. It took precious time for local emergency workers to figure out that the ambulance service was not available and to coordinate a backup plan for transporting the woman. Having to rush to the woman’s home in her own SUV, the nurse was afraid they didn’t have the time to take the unconscious woman to Boise. And the elderly woman died about 12 hours later.

When my colleague interviewed staff at the clinic and ambulance service, they said: “This kind of stuff happens all the time. We have to ship people all over the state because our docs can’t transfer to Boise. We improvise as best we can.” Our fieldwork uncovered dozens of similar situations over the following weeks. The care staff went through heroic but horribly inefficient measures to save lives in an anachronistic and antagonistic bureaucracy that didn’t serve anyone’s needs very well.

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There is something wrong in a world that has doctors and nurses paralyzed by fear of being sued if they practice medicine in a state where they are not licensed. There is something crazy going on when a patient has to be driven across an entire state instead of just across the border to a nearby city for a routine checkup. And there is something unforgivable happening when we’re eating up precious emergency resources with routine checkups in rural areas, only to leave a stroke victim to die from a system that can’t deal with border crossings from state to state.

I think it is past time to bring licensure out of the closet as an issue for national discussion. To my mind, nationalizing the licensure and credentialing of clinicians will be more efficient, effective, and affordable. It will enable doctors to practice medicine across the multiple jurisdictions and locations where their patients live and play. It will give patients access to “borderless care” that goes with them wherever they find themselves across the country. It will enable new care models around telehealth services for disease management and independent living at home from cost-effective regional call centers optimized for that kind of encounter.

If we need an emergency to do the right thing for our country, then we have one. The age wave that is upon us and the financial crisis we face due to escalating healthcare costs will impact far many more millions of lives than Katrina ever did. We have a demographic storm already pounding upon our coastline–the storm warnings are abundantly clear. So let’s put forth the emergency waivers that will allow clinicians to practice medicine across borders. Or even better, let’s rethink licensure and the power and possibilities that borderless care will bring. Sometimes emergencies do teach us things about how the world should be even in normal times, if we choose to learn from those lessons.

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