Medical Licensing By Endorsement: Requirements Differ for Graduates of Foreign and U.S. Medical Schools

Published by the Government Accountability Office on 1990-05-17.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

                     United   States   General   Accounting   Office   .+

                     Report to Congressional Committees

May 1990
                     MEDICAL LICENSING
                     BY ENDORSEMENT
                     Requirements Differ
                     for Graduates of I
                 *   Foreign and U.S.
                     Medical Schools

‘GAO/HRIW-120.                                                          j:
      United States
GAO   General Accounting  Office
      Washington, D.C. 20548

      Human Resources Division


      May 17,199O

      The Honorable Edward M. Kennedy
      Chairman, Committee on Labor and
        Human Resources
      United States Senate

      The Honorable John D. Dingell
      Chairman, Committee on Energy
        and Commerce
      House of Representatives

      A physician who holds a medical license in one state but applies for a
      license to practice in another state is seeking what is known as endorse-
      ment licensure. Medical licensure is under the jurisdiction of state and
      territorial governments; the federal government plays no role. And
      although endorsement licensure is often referred to as “reciprocity,” no
      state automatically issues licenses to physicians who apply for endorse-
      ment. Each state has its own endorsement requirements and conducts its
      own evaluations to determine if applicants meet those requirements.
      Generally, the requirements for initial and endorsement licensure are

      Many graduates of foreign medical schools (those located outside the
      Lmited States, its possessions, and Canada) believe that when they
      apply for endorsement licensure, they are subject to dissimilar and
      unfair requirements compared with those for graduates of US. medical
      schools. This report responds to the congressional mandate that GAO
      review state requirements for medical licensure by endorsement to
      determine whether any differences in state endorsement requirements
      discriminate against graduates of foreign medical schools.1 In this
      review, we applied the term “discrimination” in a general sense to mean
      any differences or distinctions between endorsement requirements for
      graduates of foreign schools and for graduates of U.S. schools. Our
      review objectives were therefore to (1) identify any differences between
      the states’ endorsement requirements for graduates of foreign medical
      schools and for graduates of U.S. medical schools and (2) determine the
      reasons for and merits of any differences.”

       ‘Ilealth OmnibusProgramsExtrnslon of 19RR,Public Law 100-607,section630 (1988).
       ‘GAO has previously reportedon issuesrelatedto initial licensure.SeePolicieson U.S.CitizensStud-
       ying MedicineAbroad NeedRewew and Reappraisal(HRD-81-32,Nov. 21,198O)and F‘ederal.State.
       and Private Activities Pertainingto 1J.S.Graduatesof ForeignMedicalSchools(HRD-85-112,
       Sept 27, 1985).

       Page 1                                     GAO/HRD90-120Medical Licensing by Endorsement

                   We did not determine whether endorsement requirements discriminate
                   against foreign school graduates on the basis of national origin or any
                   other basis that is protected under equal employment opportunity laws.
                   Such determinations are rendered through appropriate administrative
                   and legal processes and were outside the scope of our review.

                   We took several steps to identify differences between endorsement
Scope and          requirements for graduates of foreign medical schools and for graduates
Methodology        of U.S. medical schools. (See app. I.) First, we reviewed national data on
                   each state’s requirements, collected by the American Medical Associa-
                   tion (AMA) and the Federation of State Medical Boards (F-SMB). We then
                   visited six states-California,   Florida, New York, Ohio, Texas, and
                   Virginia-to    obtain more detailed information.

                   We met with officials of the six state medical licensing boards, medical
                   associations most closely related to licensure issues, and organizations
                   representing foreign medical school graduates. Our review culminated in
                   a GAO-sponsored roundtable discussion, which included participants
                   from these three groups. (See app. II for a list of participating organiza-
                   tions.) We obtained their views on the merits of any differences between
                   endorsement requirements for graduates of foreign medical schools and
                   for graduates of 1T.S.medical schools and on options to address endorse-
                   ment issues.

                   We conducted our review between March and August 1989 in accor-
                   dance with generally accepted government auditing standards.

                   Most states have differences between endorsement requirements for
Results in Brief   graduates of foreign medical schools and for graduates of U.S. medical
                   schools. These differences are evident in examination and experience
                   requirements: most states require that foreign medical school graduates
                   pass a different licensure examination and complete more years of post-
                   graduate (residency) medical training than their U.S. counterparts. In
                   contrast, in the six states for which we had data, education standards
                   and documentation requirements are generally similar for foreign and
                   U.S. medical school graduates. Exceptions exist in five of these states in
                   their requirements for documenting clerkships, patient care experiences
                   that are basic to ITS. medical school programs. Also, differences exist
                   between U.S. and foreign graduates in the effort necessary to obtain
                   education-related documents.

                   Page 2                           GAO/HRD9@120   Medical   Licensing   by Endorsement

             Roundtable participants do not agree on the merits of the different
             requirements for experience or for education documentation for foreign
             medical school graduates. However, they agree that a clearinghouse
             would be an effective way to maintain and verify documents related to
             licensure applicants’ educational backgrounds and credentials. They
             believe that a clearinghouse would be particularly useful to foreign
             school graduates who seek endorsement but have difficulty obtaining
             records from their medical schools. They believe that these physicians
             would benefit from their records being on file with a centralized

             Roundtable participants also noted that a single examination for all
             licensure applicants is being developed. They supported this effort,
             agreeing that different examination requirements for graduates of for-
             eign and U.S. medical schools have no merit, and that examinations
             should be the same for both groups in initial and endorsement licensure.

             Because endorsement data are limited, we were unable to determine the
             effect of requirements for foreign medical school graduates on their abil-
             ity to obtain licenses by endorsement in different states. The Texas med-
             ical licensing board, however, provided 1989 data indicating that most
             applicants who were foreign medical school graduates met the state’s
             endorsement requirements and were issued licenses.

             Organizations representing foreign medical school graduates believe that
Background   these graduates are subject to endorsement requirements that are
             unnecessary and different from those for their U.S. counterparts.” In a
             case example provided by the organizations, a foreign school graduate,
             licensed to practice medicine in five states, was denied licensure in a
             sixth state because the state’s medical licensing board determined that
             his medical education was not equivalent to that provided to U.S. medi-
             cal school graduates. To reach its decision, the board placed the burden
             on the physician to prove the equivalency of his education. The physi-
             cian found it difficult to address the board’s numerous inquiries, such as
             the number of faculty in his medical school and their credentials, and
             whether his school made a practice of issuing fraudulent certificates of

              “According to 1986data, the latest walkable, foreign medicalschoolgraduatescomprisedabout ‘22
              percentof the approximately 569,000physiciansin the lJnited Statesand its possessions.
                                                                                                  About 71
              percentof foreign schoolgraduateswere foreign nationals,and about 29 percentwere US. citizens.
              Amrrican MedicalAssocmtion,ForeignMedicalGraduates-SummaryData 1971to 1986,1988.

              Pagr 3                                    GAO/HRD90120      Medical   Licensing   by Endorsement

                              In contrast, FSMB, which represents all 54 licensing boards, and directors
                              of several state boards believe that the backgrounds of foreign medical
                              school graduates generally deserve more scrutiny than those of gradu-
                              ates of U.S. medical schools, For example, some of the directors
                              recounted cases of endorsement applicants who attended a particular
                              Caribbean medical school. Their boards not only questioned the quality
                              of the medical school on the basis of standards used to accredit U.S.
                              medical schools, but discovered that school officials had been involved
                              in selling graduation certificates.

                              While these examples may be exceptions for most state medical licens-
                              ing boards, they illustrate the debate over endorsement issues.

Licensing Standards           States and territories have created medical licensing boards to carry out
                              licensing activities. Among other things, they develop initial and
                              endorsement requirements, review applications, and issue or deny
                              licenses. A state board issues licenses only to physicians it deems compe-
                              tent to provide safe and effective general medical care. Currently, the
                              standards and requirements used by boards to evaluate physician com-
                              petence are not uniform. The standards can, however, be grouped in
                              three interrelated areas (see app. I):

                      l       Education standards require that a physician hold a medical degree
                              from a school that provides education and training of a quality and
                              duration acceptable to the individual board.
                      l       Examination standards require the successful completion of standard-
                              ized exams and may include oral and/or special-purpose exams.
                          l   Experience standards require postgraduate (residency) training at an
                              accredited U.S. or Canadian institution and may involve a review of the
                              physician’s character and practice history.

                               Page 4                           GAO/HRLHK%120   Medical   Licensing   by Endorsement

                      U.S. schools are accredited by the Liaison Committee on Medical Educa-
Education Standards   tion (IXME), but often foreign countries do not have a corresponding
and Documentation     organization. (See app. I.) As a result, assessing foreign school gradu-
Requirements Are      ates’ educational background and credentials is generally more difficult.
Similar               The six state medical licensing boards we visited use similar standards
                      for foreign and U.S. medical school graduates to determine if endorse-
                      ment applicants’ premedical and medical education are acceptable.4 The
                      standards are based on those used by LCME to accredit U.S. medical

                      Specific requirements for documenting educational backgrounds and
                      credentials are also similar for foreign and U.S. medical school gradu-
                      ates in all six states. The state boards closely review such information as
                      the types and dates of diplomas received, name and location of the medi-
                      cal school(s) attended, and a transcript(s) of all courses taken and
                      grades received.

                      Despite these similarities, however, five of the six states we visited have
                      documentation requirements related to clerkships that apply only to for-
                      eign school graduates.? For example, California, Florida, New York, and
                      Texas require information on the types, dates, and locations of clerk-
                      ships. California and New York also require special documentation from
                      foreign school graduates who complete clerkships in countries other
                      than where their medical schools are located. This documentation
                      includes direct verification of an applicant’s completion of each clerk-
                      ship by those responsible for monitoring the physician’s work. Virginia
                      requires that foreign school graduates who complete clerkships in Carib-
                      bean countries appear before the board to confirm information on their

                      4Becausedata are limited nationwde on states’specific educationstandardsand documentation
                      requirementsfor endorsement,we foased on thesestates.
                      “A basicpart of I1.S.medicaleducatmnand LCMEstandards,clerkshipsare patient careexperiences
                      that allow studentsto apply, m a clinical setting,the knowledgethey acquiredin their first 2 yearsof
                      medicalschool.(Seeapp. 1.)
                      “Other states-mcluding Arkansas,Montana,Nebraska,and Pennsylvania-also have specialinter-
                      view requirementsfor somr, if not all, foreign medicalschoolgraduates.Fromavailable data, we
                      could not determinewhy or how thesemterviews were conducted.However,state medicallicensing
                      boardshave usedinterviews to ask endorsementapplicantsaboutunclear or discrepantresponseson
                      applicationsand about the applirants’ medicaleducation,clinical experiences,and any negativeitems
                      associatedwith either

                      Page 5                                      GAO/HRD90.120      Medical   Licensing   by Endorsement

Obtaining Documentation     Regardless of whether documentation requirements are the same for
                            both foreign and U.S. medical school graduates, they may pose more dif-
a Problem for Some          ficulty to foreign school graduates. For example, California, New York,
Foreign School Graduates    and Texas require direct verification of education credentials and tran-
                            scripts from medical schools, and original diplomas and transcripts. For
                            graduates of U.S. medical schools, these documents are readily availa-
                            ble. But for foreign school graduates, board staff noted that such
                            schools may delay in returning this verification, thus adding weeks or
                            months to an application’s processing time. Delays may also occur when
                            foreign school graduates who did not retain their original diplomas or
                            transcripts must request copies from their medical schools. Further-
                            more, obtaining any information from certain medical schools, such as
                            those in countries without diplomatic relations with the United States,
                            can be extremely difficult or impossible.

                            Officials of the six state boards we visited believe that such problems
                            may affect only a small percentage of endorsement applicants. They
                            estimated that the average processing time for all endorsement applica-
                            tions is 8 to 12 weeks. Several of the officials noted that although some
                            foreign school graduates’ applications have required as long as 2 years
                            to process when information from medical schools was delayed, they
                            believe that such delays represent a minority of cases. Officials of the
                            six boards also stated that when documents are unobtainable, they can
                            often resort to other verification methods, such as accepting (1) verifica-
                            tion of graduation from the Educational Commission for Foreign Medical
                            Graduates (ECFMG), (2) affidavits from classmates confirming an appli-
                            cant’s educational credentials, and (3) information on file from other
                            state medical boards.; H

Disagreement on Merits of    Organizations representing foreign medical school graduates believe that
                             these graduates should not be required to provide any documentation
Documentation                other than that required of U.S. graduates. They contend that not only
Requirements                 may additional documentation be difficult to obtain, but educational
                             background has little bearing on a licensed physician’s competency,
                             unlike performance in clinical practice. (Several studies, including one in

                             ‘ECFMGis a voluntary orgamzationthat, through its programof certification, assessesthe readiness
                             of graduatesof foreign medicalschoolsto enter accreditedresidencyor fellowship program5in the
                             IJnited States.
                             ‘As an exampleof altematwe methods,California assistsrefugeephysiciansfrom Vietnam.Stab-
                             lished by law, a six-memberFaculty-in-Exile Committeeattemptsto confirm and evaluatethe medical
                             educationof physicians who attendedthe University of Saigonand fled Vietnamin the rmd-1970s
                             and early 19ROswithout official mrdlcal schoolrecords.

                             Page 6                                    ~A0/HRD90120      Medical   Licensing   by Endorsement

Florida, support the position that there are no significant differences in
the performance of U.S. and foreign medical school graduates in clinical
practice.)” (See bibliography.) The executive director of the Interna-
tional Association of American Physicians stated:

“Even though I may have come from a school which is not equivalent in standard to
that of the United States, I have taken years of American training and now I am in
practice, so judge me on my training and performance rather than on my medical
school’s background. As you know, one can get a bad doctor from the best school
and an excellent doctor from the worst school.”

Officials of state boards we visited, FSMB, and the AMA believe, on the
other hand, that each state must have the discretion to establish the
standards and requirements it deems appropriate to ensure competency.
Otherwise, they argue, a state would be forced to accept another state’s
standards even if it believed those standards did not ensure competency,
thus violating its responsibility to protect the public health. They also
believe that education provides the foundation of knowledge and abili-
ties necessary for a physician to practice general medicine competently
and that it is irreplaceable as a factor in licensing, regardless of the
number of years of practice. They add that any different education
documentation requirements for foreign graduates exist because of
problems in assessing the quality of their education due to the lack of an
accreditation organization.“’

The directors of the applicable state boards believe that the clerkship
documentation requirements discussed on page 5 are justified. They con-
sider the clerkships specified in LCME standards as providing the clinical
skills essential to the practice of general medicine. If the necessary
clerkships are not part of a medical school’s curriculum, or are deficient,
the directors argue, t,he school’s graduates may not have the broad
knowledge needed to practice general medicine. They consider this a
serious deficiency that must be mediated before a license is issued
because a license to practice medicine validates a physician’s ability to

%ecauseof limitations in thrw studies’designs,such as no assessment      of the performanceof physi-
cians from specificschools,their results are difficult for state boardsto considerin developinglicen-
sure requirementsor in rwicwing the qualifications of individual applicants
“‘In our 1980and 1985reports on initial hcensure,we and others recommendedthat the United
Statesdevelopan accreditingbody for foragn medicalschools.Our roundtableparticipants now
believethat this may not be a feasibleproposalbecausethey believeit would be expensive,difficult
to manage.and unacceptableto many countries.The participants noted that many foreign medical
schoolsand/or countries have little mterestin establishingstandardsto meetthoseof lJ.S.schools,
consldcringthat they have rhw own obJectivesfor medicaleducation.

Page 7                                       GAO/HRB9@120       Medical   Licensing   by Endorsement

                    practice general medicine. (These boards do consider whether an appli-
                    cant’s postgraduate [residency] training covered the clerkship defi-
                    ciency.) These directors are concerned that some foreign medical schools
                    do not require the LCME-specified clerkships or ensure that clerkships
                    are appropriately supervised and of an acceptable quality.ll

                    During the roundtable discussion, AMA and FSMBrepresentatives indi-
                    cated that states should carefully consider the relevance and impact of
                    their documentation requirements. For example, they believe that some
                    boards’ inquiries directed at foreign school graduates, such as the num-
                    ber of faculty in their medical schools or the number of books in their
                    school libraries, are of questionable value in endorsement considerations
                    although they are based on LCMEstandards. The AMA has urged licensing
                    boards to review their endorsement requirements with a view toward
                    simplifying them where possible. The AMA has stated:

                    “...it hardly seems necessary to confirm a medical school graduate’s high school edu-
                    cation. Similarly, it hardly seems germane to confirm the premedical education of a
                    physician who has completed specialty training. Licensing boards are perennially
                    overworked and understaffed. Simplifying the procedures for endorsement to those
                    essential to a determination of current competence could result in more time for
                    boards to spend on applications that are difficult to evaluate.”

Consensus for       All roundtable participants agreed on the desirability of a central
Clearinghouse for   clearinghouse to maintain and verify information on licensure appli-
                    cants’ educational backgrounds and credentials. They agreed that, if
Documents           properly developed, a clearinghouse for applicants’ records could
                    streamline the process for licensing by endorsement and limit duplica-
                    tive state efforts. After entry into the clearinghouse, an applicant’s doc-
                    uments would be verified and on file for ready access. Roundtable
                    participants believe that a clearinghouse could help reduce the burden
                    on foreign school graduates who may have difficulty in obtaining
                    records from foreign medical schools, especially years after they

                    As a result of the roundtable discussion, representatives of several orga-
                    nizations, such as the AMA, FSMB,ECFMG,and the International Associa-
                    tion of American Physicians, agreed to coordinate efforts to develop the

                     ’ ‘Hecausesomeforeign medicalschoolsdo not have accessto adequateclinical training facilities in
                     their countries,somefore@ schoolstudentsseekclerkshipselsewhere,including in U.S.hospitals.In
                     1980and 1985reports,we indicated that the quality and supervision of many of theseclerkships
                     were insufficient.

                     Page 8                                     GAO/HRLNO-120     Medical   Licensing   by Endorsement

                   clearinghouse’s concept and design. They also agreed to address basic
                   questions, such as which organization would be best suited for adminis-
                   tering the clearinghouse and what types of information it would main-
                   tain. Moreover, they indicated that state licensing authorities should be
                   consulted to ensure that the clearinghouse meets their needs. As of Jan-
                   uary 1990, the AMA had taken some steps to develop the concept for
                   both US and foreign medical school graduates, and its representatives
                   indicated they would coordinate with the other organizations. A spokes-
                   person for the project emphasized, however, that developing a national
                   clearinghouse could take several years.

                   For physicians seeking endorsement, examination requirements for
Examination        graduates of U.S. medical schools are different in most states from those
Requirements Are   for graduates of foreign medical schools. Graduates of U.S. schools gen-
Different          erally may select either of two standardized examinations, whereas
                   graduates of foreign schools do not have the choice. The National Board
                   of Medical Examiners (NBME) certifying exams and the Federation
                   Licensing Exam (FLEX) are the standardized exams available to US.
                   school graduates. (See app. I for exceptions.) Only the FLEX is available
                   to foreign school graduates.”

                   Also, most states require that the FLEX be taken in a single sitting, last-
                   ing about 3 days.‘:’ In contrast, the NRME certifying exam, which about
                   three-fourths of U.S. medical school graduates choose to take for licen-
                   sure, is administered in parts at different points throughout a student’s
                   medical education. (See app. I.)

                   Some states also place a time limit on accepting the scores received on
                   the FLEX. Florida, for example, accepts FLEX scores for 10 years, after
                   which physicians must take the entire examination again. Organizations
                   representing foreign school graduates consider this an extremely diffi-
                   cult task for physicians who have been out of medical school for several

                   “All but New Jerseyand PuertoRico alsorequire that foreign medicalschoolgraduatesbe certified
                   by ECFMG.Certification involves other examinationsbeforethe FLEX, including the ForeignMedical
                   GraduateExamination in MedicalSciences(FMGEMS).(Seeapp. I.) (New Jerseystill requires,how-
                   ever, that foreign medicalschoolgraduatespassFMGEMS.)AmericanMedicalAssociation,U.S.Medi-
                   cal LicensureStatisticsand Current LicensureRequirements:1989Edition, 1989.
                   “‘In 1987,31jurisdictions required the FLEX in a single sitting. AmericanMedicalAssociation,-U.S.
                   MedicalLicensureStatisticsand Current LicensureRequirements:1989Edition, 1989.

                   Page 9                                      GAO/HRD90-120Medical Licensing by Endorsement

                   In addition, some states, such as Alabama, California, and Idaho,
                   require, under some circumstances, that only foreign medical school
                   graduates take oral examinations for endorsement. For example, Cali-
                   fornia requires an oral exam of each foreign school graduate, regardless
                   of years of licensed practice, but only requires an oral exam of U.S.
                   graduates who have been licensed over 4 or 5 years. The 30-minute
                   exam requires that an applicant logically diagnose a common medical
                   problem, such as chest pain, jaundice, or coma, and know what basic
                   therapeutic procedures to institute.

                   Participants in the roundtable agreed that examination requirements for
                   licensure should be the same for foreign and U.S. medical school gradu-
                   ates, considering that the knowledge and skills covered in examinations
                   are the same for all licensure applicants. The major medical associa-
                   tions, in consultation with the state boards, are already moving to a
                   “single examination pathway to licensure” for both foreign and U.S.
                   school graduates, which an FSMB official expects will be implemented in

                   Over 30 state medical licensing boards require more years of accredited
Experience         U.S. or Canadian postgraduate training for foreign medical school grad-
Requirements Are   uates than for U.S. school graduates who seek licensure. (See apDs.
                                                                                  -.   III
Different          and IV.)

                   Organizations representing foreign medical school graduates argue that
                   there should be no difference in the number of years of postgraduate
                   training required for licensing foreign and U.S. school graduates. They
                   believe that whatever requirement a state haa established for U.S.
                   school graduates is also adequate for foreign school graduates.

                   The six state board directors we interviewed and FSMB are divided on the
                   amount of postgraduate training needed before initial or endorsement
                   licensure. Some of the directors believe that additional postgraduate
                   training for foreign school graduates is necessary to alleviate possible
                   education deficiencies. In contrast, FSMB believes that 2 years of training
                   is adequate for both U.S. and foreign graduates because most physicians
                   eventually become specialists and because specialty boards require at
                   least 2 years of postgraduate training in a specialty area for certifica-
                   tion. (See app. I regarding specialty board certification.)

                   The AMA opposes “lengthy” postgraduate training for all initial or
                   endorsement licensure applicants and encourages state medical boards

                   Page 10                          GAO/HRB90120   Medical   Licensing   by Endorsement

                      to consider a physician’s practice of medicine in reviewing endorsement
                      applications. The AMA has stated:

                      “Boards considering an application for endorsement of a license appear to ignore
                      years of competent and honorable practice of medicine while confirming graduation
                      from medical school and the successful passing of licensing examinations, even if
                      these were done many years before. Physicians can be refused licenses based on
                      requirements that might be superceded by years of competent practice.”

                      The state boards we visited do not consider the number of years a physi-
                      cian has been in practice as a significant factor in reviewing endorse-
                      ment applications because of the difficulty in assessing its value.
                      Several of the state board directors we interviewed noted that a specific
                      number of years of practice does not itself guarantee competency. The
                      six boards will consider indicators of incompetency, however, in review-
                      ing licensure applications, on the basis of malpractice confirmed by
                      court judgments or other adverse actions.

                      Because data are limited both nationwide and for the six states
Data Too Limited to   reviewed, the effect of requirements on foreign medical school gradu-
Determine Effect of   ates’ obtaining endorsement licensure is uncertain. Many state medical
Requirements on       licensing boards do not keep records on whether physicians are being
                      licensed for the first or additional times in their careers or if physicians
Endorsement           who are licensed by endorsement are foreign or US. medical school
                      graduates. As a result, data are not available nationwide or in five of
                      the six states we visited for foreign and U.S. medical school graduates to
                      compare (1) the number of endorsement applications that resulted in
                      license issuances or denials; (2) length of application processing times,
                      from submittance to decision on issuance or denial; or (3) the number of
                      withdrawals from the application process.

                      The Texas board provided us data showing that in fiscal year 1989, the
                      board denied licenses by endorsement to only four U.S. and five foreign
                      medical school graduates out of more than 700 applications (over 500
                      for U.S. school graduates and over 200 for foreign school graduates).
                      Although we could not verify all the data, it appears that while there
                      were more licenses by endorsement denied graduates of foreign medical
                      schools, the state’s endorsement requirements for foreign school gradu-
                      ates have posed little, if any, barriers to licensing. (See app. V.)

                      Texas licensing officials believe that the fiscal year 1989 data are repre-
                      sentative of preceding years. Officials of other state boards we visited

                      Page 11                              GAO/HRBW120    Medical   Licensing   by Endorsement

              also believe that the vast majority of foreign school graduates who
              apply for endorsement in their states, like U.S. school graduates, receive
              their licenses. However, data were not available to verify this

              Because the states have no uniform standards or requirements to deter-
Conclusions   mine competence, most states have different endorsement requirements
              for graduates of foreign and U.S. medical schools. Opinions on the merits
              of these differences vary among organizations representing foreign med-
              ical school graduates, state medical licensing boards, and medical
              associations, Their viewpoints, along with other evidence we reviewed,
              reflect the lack of a consensus among members of the medical profession
              on the specific standards and requirements necessary to determine com-
              petency. In general, the AMA, FSMB, and directors of state medical licens-
              ing boards we visited disagree with organizations representing foreign
              school graduates on the merits of different requirements related to doc-
              umentation of educational background. The groups’ opinions on the mer-
              its of different experience requirements also differ, as some of the state
              board directors believe that differences have merit, while F-SMB and orga-
              nizations representing foreign school graduates support a contrasting
              position. But representatives of all of the groups agree that different
              examination requirements for foreign medical school graduates have no

              Representatives of the groups also agree on the desirability of a
              clearinghouse to maintain and verify records. The clearinghouse should
              help to eliminate states’ duplicative verification efforts and streamline
              the licensing process. It should also be of particular assistance to foreign
              school graduates who may experience difficulty in obtaining documen-
              tation of educational background and credentials from their medical

              We are sending copies of this report to interested congressional members
              and will make copies available to others on request.

              Page 12                           GAODIRD-g&120   Medical   Licensing   by Endorsement

If you or your staff have any questions about this report, please call me
on (202) 275-1655. Other major contributors to this report are listed in
appendix VI.

Linda G. Morra
Director, Intergovernmental
   and Management Issues

 Page 13                         GAO/HlUNW-120   Medical   Licensing   by Endorsement

Letter                                                                                                         1

Appendix I                                                                                                16
Background               Determining Competence: The Three F’illars of Medical                            16
                         Objectives, Scope, and Methodology                                               19

Appendix II                                                                                               22
Organizations            Medical Associations                                                             22
                         Federal and State Organizations                                                  22
Contacted for This       Organizations Representing Foreign Medical School                                22
Review                       Graduates

Appendix III                                                                                              23
Training: States With
the Same Versus
Different Licensure
Requirements for
Foreign and U.S.
Medical School
Appendix IV                                                                                                24
Postgraduate Training
Required for Licensing
Foreign and U.S.
Medical School

                         Page 14                         GAO/HRB90120   Medical   Licensing   by Endorsement

Appendix V                                                                                           26
Texas Endorsement
Applications and
Licenses Issued and
Denied in Fiscal Year
Appendix VI                                                                                           27
Major Contributors to
This Report
Bibliography                                                                                          28


                        AMA        American Medical Association
                        ECFMG      Educational Commission for Foreign Medical Graduates
                        FLEX       Federation Licensing Examination
                        FMGEMS     Foreign Medical Graduate Examination in Medical Sciences
                        FSMB       Federation of State Medical Boards
                        GAO        General Accounting Office
                        LCME       Liaison Committee on Medical Education
                        NBME       National Board of Medical Examiners

                        Page 16                         GAO/~90-120   Medical   I.kem~   by Endorsement
Appendix I


                    To carry out medical licensing activities, the states and territories have
                    created medical agencies or boards composed of physicians and nonphy-
                    sicians. These state boards, as well as state legislatures, develop specific
                    standards and requirements for endorsement. Based on these standards
                    and requirements, the state boards review applications and issue
                    endorsement licenses to applicants they deem competent to provide
                    effective general medical care. This process is distinct from specialty
                    board certification, which is voluntary and designed to recognize a phy-
                    sician’s ability to practice a medical specialty.’

                    The competence of physicians is related to medical knowledge and per-
Determining         formance and therefore involves the application of knowledge to spe-
Competence: The     cific clinical problems, the judgment exhibited in choosing among
Three Pillars of    available options, and interpersonal relationships with patients and
                    other health care professionals.2 At present, the states do not have uni-
Medical Licensure   form standards or requirements to determine minimum competence.
                    However, standards for assessing knowledge and performance have
                    evolved in three interrelated areas, often referred to as the three “pil-
                    lars” of medical licensure: education, examination, and experience.

Education           The general purposes of education requirements are to confirm that a
                    physician has a medical degree and to assess the quality of the educa-
                    tion and training provided by the medical school. To make its evalua-
                    tion, a state medical licensing board may require documentation of
                    graduation and curriculum, such as diplomas and transcripts. For gradu-
                    ates of U.S. medical schools, these documents are readily available, and
                    the quality of the schools’ education and training have already been
                    evaluated by an accrediting organization.

                    The Liaison Committee on Medical Education (LCME) is responsible for
                    establishing standards of accreditation for U.S. and Canadian medical
                    schools and for determining, through periodic inspections, if the stan-
                    dards have been met. LCME includes representatives from the American
                    Medical Association (AMA), the Association of American Medical Col-
                    leges, the Committee for the Accreditation of Canadian Medical Schools,

                    ‘Specialty boardsare national entities establishedvoluntarily by the medicalprofessionto ensure
                    that physicians who seekcertification have passedevaluation proceduresthat permit them to be
                    designatedas specialists Specialty boardcertification is not a prerequisitefor licensure.
                    ‘American MedicalAssociation,Future Directionsfor Mednl Educatmn,1982 Also. seeThe Task
                    Forceto Study Pathwaysto L~censure.A Proposalfor a SingleExamination for MedicalLicensure.

                    Page 16                                    GAO/HRB9&120 Medical Licensing by Endorsement
                Appendix I

                the federal government, and the public. LCME standards help to ensure
                that medical schools provide the skills and experience to prepare stu-
                dents for postgraduate medical education and licensing. The standards
                include, but are not limited to, the following:

              . Balance between the size of each class enrollment and the total program
                resources, including the faculty, physical facilities, and budget.
              . An instruction program of 130 weeks, preferably scheduled over a mini-
                mum of 4 calendar years.
              . A curriculum that includes the basic sciences of anatomy, biochemistry,
                physiology, microbiology and immunology, pathology, pharmacology
                and therapeutics, and preventive medicine.
              . Patient care experiences, known as clerkships, in internal medicine,
                obstetrics and gynecology, pediatrics, psychiatry, and surgery. (In the
                third and fourth years of U.S. medical education, clerkships allow stu-
                dents to apply, in a clinical setting, the knowledge they acquired in their
                first 2 years of medical school. Students are in direct contact with
                patients at this point; however, they do not have primary responsibility
                for patient care, as they are directed and supervised by members of the
                faculty and resident staff.)

                Because foreign countries often do not have an accreditation organiza-
                tion like LCME, assessment of foreign school graduates’ educational
                backgrounds and credentials is generally more difficult. In lieu of an
                accrediting organization, the state boards we visited use LCME standards
                to assess the equivalency or comparability of foreign school graduates’
                education to that of U.S. school graduates? This assessment requires
                documentation from the applicant or, in some of these states, foreign
                medical schools. The boards or endorsement applicants may experience
                problems in obtaining documentation, such as applicant records and
                information on program content, from foreign schools.

Examination      State licensing authorities require that endorsement applicants demon-
                 strate a satisfactory level of medical knowledge through national, stan-
                 dardized examinations. In addition, some states have other exams, both
                 oral and/or written. For example, the Special Purpose Exam, a test of
                 general medical knowledge, may be required of groups of physicians,

                 ‘As a result of applying IL?MEstandards,as of March 1989,the Cabformaboardhad disapproved
                 low medicalschools,all locatedin Canbbeancountries,for swh problemsas fraudulent documents
                 or inadequateor nonexistent trainmg The board will not considerwork doneat theseschoolsafter
                 Thc cffrctiw date of disappnwrl

                 Page 17                                  GAO/HI@-SO-120    Medical   Licensing   by Endorsement
  Appendix I

  such as those who are 5 years or more beyond medical school

  The major standardized licensure exams are described below:

. The National Board of Medical Examiners (NBME) exams consist of three
  parts. Parts I and II, written (multiple-choice) examinations, cover the
  basic medical and clinical sciences, respectively, and are usually taken
  during medical school before postgraduate medical education. Part III, a
  written exam that tests a student’s ability to perform in the unsuper-
  vised practice of medicine, cannot be taken before the student partici-
  pates in postgraduate (residency) training. Only graduates of accredited
  U.S. and Canadian medical schools who have passed parts I and II are
  eligible for part III.
. The Federation Licensing Examination (EZEX),sponsored by the Federa-
  tion of State Medical Boards (FSMB), has two parts: (1) a 1-l/2-day writ-
  ten (multiple-choice) exam designed to evaluate knowledge of the basic
  medical and clinical sciences and (2) a 1-l/2-day written examination
  designed to test a physician’s ability to diagnose and manage common
  clinical problems. While all state medical licensing boards require for-
  eign medical school graduates to pass the FIxX for endorsement, only
  Louisiana, Texas, and the Virgin Islands require the FLEX of U.S. medical
  school graduates.: t~

  In addition, almost all jurisdictions require that foreign medical school
  graduates be certified by the Educational Commission for Foreign Medi-
  cal Graduates (ECFMG). Certification, a prelicensing process, assesses the
  readiness of foreign school graduates to enter accredited residency or
  fellowship programs in the United States. To obtain ECFMG certification,
  foreign medical school graduates must pass

  ‘Somestatesmay have other specialexamsfor foreign medicalschoolgraduates.For example,Ohio
  requires a test of spokenEnglish, conductedby the EducationalTesting Service.Ohio alsoadministers
  a one-of-a-kindtest of cbnical skills, known as the MedicalEducationEvaluation Program,for a select
  group of foreign schoolgraduates:physicians who were Ohio residentsbeforemedicalschool,did not
  receiveunrestricted rights to practicein the countrieswhere they completedtheir medicaleducation,
  and whosediplomaswere not approvedby the Ohio board.
  “In 1968,FSMBintroduced the FLEX to promoteuniform hcensurestandards.Louisiana,Texas,and
  the Virgin Islandselectid to require it of both foreign and US medicalschoolgraduates
  “Lou&ma’s acceptanceof passageof the NBMEexamsis limited, as endorsementapplicantswho
  graduatedfrom accreditedI’.S. or Canadianschoolson or after January 1,1978,must alsopassthe
  clinical competenceportion of the FLEX. Texasacceptsthe NBMEexamsonly if part III was passed
  beforeJanuary 1,1978. In all other cases,applicantsmust passthe FLEX, the SpecialPurpwz Exam,
  or be specialty board certified. The Virgin islands do not have endorsementprovisions for the NBME
  exams,as all endorsementapplicantsmust passthe FLEX. AmericanMedicalAssociation,US. Medi-
  cal lxensure Statistics and Current ticensure Requirements-1989Edition, 1989.

  Page   18                                  GAO/HRD-90.120     Medical   Licensing   by Endorsement
                                 Appendix I

                         l       the Foreign Medical Graduate Examination in Medical Sciences (FMGEMS),
                                 a test of basic medical and clinical sciences, or parts I and II of the NBME
                                 examinations; and
                         l       a standardized examination demonstrating proficiency in the English
                                 language.’ *

Experience                       Experience requirements relate to postgraduate training, most often
                                 referred to as a residency, in an accredited U.S. or Canadian program.!1
                                 Residencies differ from clerkships in that residents are required to take
                                 direct responsibility for caring for patients, from the point they are
                                 admitted to hospitals until they are discharged. This includes ordering
                                 diagnostic procedures and medications under the general supervision of
                                 an attending physician.

                                 State medical licensing boards may also have “character” and/or “fit-
                                 ness” requirements that involve reviewing an endorsement applicant’s
                                 practice history. For example, a physician may be required to (1) be
                                 physically, mentally, and professionally capable of practicing medicine
                                 in a manner acceptable to the licensing authority or (2) not have been
                                 found guilty of conduct that would constitute grounds for disciplinary
                                 action by the licensing authority.

                                 In response to the congressional mandate, our objectives were to
Objectives, Scope, and
Methodology                  l   identify any differences between states’ endorsement requirements for
                                 graduates of foreign medical schools and those for graduates of U.S.
                                 medical schools and
                             l   determine the reasons for and merits of any differences.

                                 ‘ECF’MGcertification alsoinvolves verifying medicalschoolgraduation and credentialsand determiw
                                 ing whether graduateshave met the educationalrequirementsto practicemedicinein the country
                                 where they completedtheir medicaleducation
                                 “Becauseparts I and II of the NBMEexamsare equivalent to the FMGEMS,they are an option for
                                 graduatesof foreign medicalschoolswho seekpostgraduatemedicaltraining in the U.S.ECFMG
                                 intends to discontinuethe FMGEMSwith the advent of a singleexaminationfor licensurefor both
                                 foreign and United Statesmedicalschoolgraduates.
                                 “The Accreditation Council for GraduateMedibalEducation(ACGME)1sresponsiblefor assuringstate
                                 medicallicensingboardsof the quality of U.S.programs The council is composedof representatives
                                 of the AmericanBoardof MedicalSpecialties,the AmericanHospital Association,the AMA, the Ass0
                                 ciation of AmericanMedicalO~lleges.the Councilof MedicalSpecialtySocieties,the federal govern-
                                 ment, and the public.

                                 Page 19                                   GAO/HRDW-120      Medical   Licensing   by Endorsement
Appendix I

We took several steps to identify differences in endorsement require-
ments. First, we obtained, but did not verify, data on each state’s
requirements from the AMA and FSMB. We then visited six states-cali-
forma, Florida, New York, Ohio, Texas, and Virginia-to     obtain more
detailed information. We selected these states because they (1) represent
nearly 48 percent of the foreign medical school graduates in the United
States, (2) vary in the number and nature of specific endorsement
requirements for foreign medical school graduates, (3) include states for
which organizations representing foreign medical school graduates pro-
vided examples of applicants’ experiences in applying for endorsement,
and (4) are geographically dispersed.

We also took several steps to determine the rationale for and merits of
any differences in endorsement requirements for foreign school gradu-
ates. First, using a structured interview guide, we met with state licens-
ing officials to discuss and obtain documentation on (1) the history and
rationale of their state’s endorsement requirements; (2) the significance
of an endorsement applicant’s medical education, history of licensing
examinations, and clinical experience in licensure considerations; and
(3) the issues in endorsement licensing, as well as their solutions. In
addition, we compared standards used by LCME to evaluate U.S. medical
schools with standards used by each state to evaluate the educational
backgrounds of foreign school graduates.

Second, we also interviewed officials of (1) the AMA, FSMB, and other
medical associations concerned with medical licensure and (2) organiza-
tions representing foreign medical school graduates. In addition, we con-
vened a meeting of officials of organizations representing foreign
medical school graduates to obtain their views on endorsement issues,
along with any suggestions for resolution. We also reviewed documents
from these groups, published literature on the competency of foreign
and U.S. medical school graduates, and legal decisions involving medical

Third, our review culminated in a GAO-sponsored roundtable discussion,
which included participants from the major medical associations, state
licensing authorities, and foreign graduate advocacy organizations. (See
app. II for a list of participants.) The purposes of the discussion were to
obtain participants’ views on the merits of any differences between
endorsement requirements for graduates of foreign medical schools and
for graduates of U.S. medical schools and to discuss potential solutions
to endorsement issues and identify areas of consensus.

Page 20                          GAO/HBD90-120   Medical   Licensing   by Endorsement
Appendix I

We conducted our review between March and August 1989 in accor-
dance with generally accepted government auditing standards.

Page 21                       GAO/HRB90-120   Medical   Licensing   by Endorsement
Organizations Contacted for This Review

                       Administrators in Medicine]
Medical Associations   American Medical Association*
                       Association of American Medical College9
                       Educational Commission for Foreign Medical Graduates’
                       Federation of State Medical Boards’
                       National Board of Medical Examiners’

                       California Board of Medical Quality Assurance
Federal and State      Department of Health and Human Services’
Organizations             Division of Quality Assurance and Liability Management
                       Florida Board of Medicine
                       New York State Board for Medicine’
                       Ohio State Medical Board
                       Texas State Board of Medical Examiners
                       Virginia State Board of Medicine

                       International Association of American Physician&
Organizations             American College of International Physicians
Representing Foreign      American Association of Physicians from India
Medical School            Association of Pakistani Physicians
                          Association of Philippine Physicians in America
Graduates                 Islamic Medical Association
                          International Medical Council of Illinois
                       Parents League of American Students of Medicine Abroad

                       I Representedat GAO’sroundtablediscussion.

                       Page 22                                GA0/HRB90.120   Medical   Licensing   by Endorsement
Postgraduate Training: States With the Same
Versus Different Licensure Requirements for
Foreign and U.S. Medical School Graduates

                     L-J     Same Number of Years of Training for All Graduates
                             AddItional Years of Training for Foreign School Graduates

               Source The Federation of State M&x       Boards of the Unlted States, Inc , The 1989/1990 Exchange,

               Page 23                                         GAO/HRLNO-120        Medical   Licensing   by Endorsement
Appendix IV

Postgraduate T&kg     Required for Licensing
Foreign and U.S. Medical School Graduates

               Figures in years
                                                  Foreign school                U.S. school
               State                                    graduates                graduates
               Alabama                                              1                         1
               Alaska                                               1                         1
               Arizona                                              3                         1
               Arkansas                                             1                         1
               Calrfornia                                           1                         1
               Colorado                                             3                         1
               Connecttcut                                          2                         2
               Delaware                                             3                         1
               District of Columbia                                 1                         1
               Flortda                                              1                         1
               Georgia                                              3                         1
               Guam                                                 1
               Hawart                                               2
               Idaho                                                3                          1
               lllinots                                             2                          2
               Indiana                                              2                          1
               Iowa                                                 1                          1
               Kansas                                               1”                         1
               Kentucky                                             3                          1
               ioursrana                                            3                          0
               Maine                                                3                          2
               Maryland                                             1                          1
               Massachusetts                                        2                          1
               Mtchigan                                             2                          2
               Mtnnesota                                            2                          1
               Mtssissrppr                                          3                          1
                Missour                                             3                           1
                Montana                                             3                           1
                Nebraska                                            3                           1
                Nevada                                              3                          3
                New Hampshtre                                       2                          2
                New Jersey                                          3                           1
                New Mexrco                                          2                           1
                New York                                            3                           1
                North Caroltna    --                                3                           1
                North Dakota                                        3                           1
                Ohro                                                2                           1
                Oklahoma                                            1--~__                      1

                Page 24                GAOiHRDSO-120   Medical   Licensing   by Endorsement
Appendh IV
Postgradllate Traning  Required for Licensing
Foreign and U.S. Me&xl   school Graduates

                                                            Foreign   school                 U.S. school
State                                                             graduates                   graduates
Oregon                                                          -               3                          1
Pennsylvania                                                                    3                          2
Puerto Ricoa
Rhode island                                                                    3                          1
South Carolina                                                                  3                          1
South Dakota                                                                    2                          2
Tennessee                                                                       la                         0
Texas                                                                           3                          1
Utah                                                                            1                          1
Vermont                                                                         1                          1
Virgin lslandsb
Vlrginla                                                                         3                         1
Washlnaton                                                                       2                         2
West Vlrglnla                                                                    3                         1
Wisconsin                                                                        1                         1
Wyoming                                                                          2                         1
Note The information I” this append{,: indicates requirements for current graduates
al year for graduates of approved schools, 3 years for graduates of nonapproved schools.
bNo lntormatlon prwded
Source The Federation of State MedIcal Boards of the United States, Inc The 1989/1990 Exchange,

Page 25                                       GAO/HBD9o12O          Medical   Licensing   by Endorsement
Appendix V

Texas Endorsement Applications and Licenses
Issued and Denied in Fiscal Year 1989

                                                                    U.S. school       Foreign school
                                                                     graduates              graduates          Total
               Applications                                                   515                    227         742
               Licenses Issued                                                529a                   216         745
               Aoollcations denied                                              4                      5           9
                 Unapproved U.S. clerkshlps                                                             3              3
                 InsuffIcIent postgraduate traimng                                1                     2              3
                 Impaired (e.g., substance abuse,
                    ohvslcal dlsabllitvi                                          2                                    2
                 Incompetent                                                      1                                    1

               aThe higher number of licenses issued than appllcatlons Indicates the overlap of the procewng of some
               appllcatlons from one ftscal year to the next

               Page 26                                      GAO/lUtD90120      Medical   Licensing   by Endorsement
Appendix VI

Major Contributors to This Report

                   Susan D. Kladiva, Assistant Director, (202) 523-9076
Human Resources    Joel A. Hamilton, Evaluator-in-Charge
Division,          Edith L. Lassegard, Intern
Washington, D.C.   Dr. Murray Grant, Chief Medical Advisor
                   Sheila M. Smythe, Chief Health Policy Advisor

                   Page 27                          GAO/HRD.9@120   Medical   Licensing   by Endorsement

               The following sources provided information related to the performance
               comparison of foreign and U.S. medical school graduates in clinical

               Committee for Fairness and Equity in Medicine. “U.S. Medical School
               Graduates More Likely to Be Sued than FMGs.” FMG Newsletter, Vol. 2,
               May 1986.

               Conn, H. “Assessing the Clinical Skills of Foreign Medical Graduates.”
               Journal of Medical Education, Vol. 61, November 1986.

               Heilmann, R. “An Attempt to Measure the Relative Quality of Care
               Delivered by FMGs and IJSMGs.” Socioeconomic Issues of Health, 1978.

               Mejia, A., H. Pizurki, and E. Royston. Foreign Medical Graduates. Lex-
               ington, MA., Lexington Books, 1980.

               Mick, S. “Contradictory   Policies for FMGs.” Health Affairs, Vol. 6, No. 3,
               Fall 1987.

               Rhee, S-O. “Factors Determining the Quality of Physician Performance
               in Patient Care.” Medical Care, Vol. 14, 1976.

               Rhee, S-O. “U.S. Medical Graduates Versus Foreign Medical Graduates:
               Are There Performance Differences in Practice?” Medical Care, Vol. 15,

               Rhee, S-O. and others. “USMGs Versus FMGs: Are There Performance
               Differences in the Ambulatory Care Setting?” Medical Care, Vol. 24,

               Saywell, R., and J. Studnicki. The USMG-FMG Quality of Care Study.
               The Johns Hopkins Ilniversity School of Hygiene and Public Health,
               Department of Health Services Administration, 1976.

               Saywell, R., and others “A Performance Comparison: USMG-FMG
               Attending Physicians.” American Journal of Public Health, Vol. 69.
               No. 1. 1979.

               Saywell, R., and others. “A Performance Comparison: USMG-FMG House
               Staff Physicians.” American Journal of Public Health, Vol. 70, No. 1,

               Page 28                           GAO/HRD90-120   Medical   Licensing   by Endorsement

           Schwartz, W., and D. Mendelson. “Physicians Who Have Lost Their Mal-
           practice Insurance: Their Demographic Characteristics and the Surplus-
           Lines Companies That Insure Them.” Journal of the American Medical
           Association, Vol. 262, No. 10, September 8, 1989.

           Sloan, F., and others. “Medical Malpractice Experience of Physicians:
           Predictable or Haphazard‘?” Journal of the American Medical Associa-
           t&, Vol. 262, No. 23, December 15, 1989.

           Stevens, R., L. Goodman, and S. Mick. The Alien Doctors: Foreign Medi-
           cal Graduates in American Hospitals. New York: John Wiley and Sons,
           Inc., 1978.

           US. General Accounting Office. Medical Malpractice: Characteristics of
           Claims Closed in 1984, 1987, Washington, D.C.

(118264)    Page 29                        GAO/HRD90-120   Medical   Licensing   by Endorsement

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