Mandated State Medical Licensing Board Disclosures Regarding Resident Performance

Established in 1981, the Accreditation Council for Graduate Medical Education (ACGME) is responsible for accrediting residency programs in the United States. In 2001, to promote appropriate outcomes, the ACGME and the American Board of Medical Specialties (ABMS) established 6 core competencies comprised of patient care, medical knowledge, professionalism, interpersonal and communication skills, practice-based learning and improvement, and systems-based practice.¹  In 2013, the ACGME and the ABMS introduced the Milestones to help provide descriptive, longitudinal narratives for trainee performance within the 6 competencies.²  When residents either complete or separate from a training program, the program director (PD) is required to complete documentation by means of verification of training (VOT) forms for a myriad of entities. These forms differ in the types of questions asked and are requested by a variety of institutions.

State medical licensing boards have the responsibility of protecting the public by ensuring that only qualified physicians obtain the right to practice medicine. While graduated residents have achieved benchmarks set forth by the ACGME and ABMS, medical licensing boards have different standards by which they grant licensure. Although the Federation of State Medical Boards (FSMB) oversees 70 state medical boards (allopathic and osteopathic) in the United States, it lacks the authority to nationally standardize the process, leading to much variation from state to state. This may be attributed to the fact that regulation of this process has been granted to the states under the Tenth Amendment of the US Constitution.³  The FSMB attempted to standardize the credentialing process by creating the Federation Credentials Verification Service (FCVS), but not all states participate. Since 1996, the FCVS is a repository of physician data, based on factors (such as identity, education, training, and employment) that are self-reported and primary source verified.³ 

Residency leadership is tasked with summarizing trainee performance using VOT forms for state medical licensure to be granted. The primary objective of this study is to determine what information PDs are required to disclose regarding academic performance during residency training.

This study was performed at an academic institution by a team of current and former PDs and educators from 6 different medical specialties. An online search of VOT forms for allopathic medical licensure was conducted in 2018 for all 50 states, Washington, DC, and 5 US territories (Guam, US Virgin Islands, Northern Mariana Islands, American Samoa, and Puerto Rico). This included retrieval of VOT forms and review of the medical licensure application process for US medical school graduates. Notation of the optional or required utilization of the FCVS by each state was made. In circumstances where it was not clear via online search what VOT form was used, e-mail or telephone confirmation was made.

All forms were reviewed for questions pertaining to trainee performance. We defined trainee performance as the level of achievement in any of the 6 core competencies. The VOT questions were categorized as follows: disciplinary actions, documents placed on file, actions taken by residents, and non-disciplinary actions taken by the program. We considered questions to be about disciplinary actions if they asked if the applicant had ever been formally disciplined, placed on probation, dismissed, suspended, restricted or had privileges restricted, terminated, expelled, asked to resign, removed from patient care, investigated or placed under investigation, or if they had adverse charges or reactions. Questions that asked if the residents took a leave of absence or break during training, requested to be transferred from the program, or had any unexcused absences were categorized as “actions taken by residents.” The non-disciplinary actions include remediation, partial credit, extra training, non-promotion, and non-renewal. In the instances where the FCVS was optional, only data from the state's own separate VOT form were included.

A data abstraction form was created and used to tally all information (provided as online supplemental material). There was agreement of all categories by 3 of the authors (M.G., M.A., D.M.) prior to data collection. Blank abstraction forms were given to the authors who reviewed all VOT forms independently with results compared and all discrepancies jointly resolved. A fourth independent reviewer (T.M.) confirmed all results.

States or territories that had either no questions regarding resident performance or did not have a VOT form were also noted. Questions pertaining to mental health and substance abuse were not included in this review and neither were forms required by the osteopathic medical boards. In addition, any alternative forms pertaining to VOT required for graduates from international medical schools were not included in this study.

This study was granted exemption from review by the Rutgers University Institutional Review Board.

A total of 56 VOT forms were located and reviewed for content. These forms included all 50 states, Washington, DC, and US territories.

The use of the FCVS with its standardized VOT form is mandated in 10 states (figure). There are 45 states/territories that accept but do not mandate FCVS use. There are 33 states with their own VOT form, 8 of which have no questions related to trainee performance. These 33 states accept the FCVS in lieu of their VOT form. American Samoa has no specific VOT form and does not accept the FCVS.

States inquired most frequently about disciplinary actions, followed by resident actions and documents placed on file. Only 7 states asked about non-disciplinary actions (table 1). Three-quarters of states asked whether a resident was placed on probation or disciplined, and two-thirds asked whether a resident was placed under investigation, took a leave of absence, or had a break in training. Questions about professionalism were uncommon, with only 3 states asking whether a patient complained about the resident (table 2).

The VOT form used by the FCVS asks questions related to probation, investigation and disciplinary action, negative reports or documents related to limitations or special requirements, and whether the applicant took a leave of absence or break in training.

Questions asking whether the applicant has ever been placed on probation (43 states), disciplined (41), or investigated or placed under investigation (37) were the most common (table 2). The least common questions regarding disciplinary actions used terminology such as suspended (8), restricted (7), terminated (5), asked to resign (4), adverse charges or actions (4), expelled (1), dismissed (1), or removed from patient care (1).

The most commonly asked questions (34 states) were regarding documentation pertaining to limitations or special requirements because of academic incompetence, disciplinary problems, or any other reason (table 2). Approximately half of the states/territories (25) asked if there were any negative reports filed for behavioral reasons. Less frequently asked questions included whether the resident was issued a letter of reprimand or warning (3), whether there were any formal staff or patient complaints (3), whether there was an official record reflecting disciplinary action for unprofessional conduct or behavioral reasons (1), or whether incident reports were filed (1).

Thirty-four states/territories asked whether the applicant took a leave of absence or had a break in training. Unexcused absences and requests to transfer were asked by 1 state.

Seven states inquired about non-disciplinary actions taken by the program. Three states (Hawaii, Minnesota, and Nebraska) inquired whether the applicant had ever been placed on remediation. Three states asked whether the applicant had not been renewed, and an additional 3 states asked about non-promotion. Two states asked if the applicant required extra training.

Only 5 states (California, Maryland, Minnesota, Texas, and Wisconsin) asked at least 1 question in each of the 4 categories (table 1). Although Virginia accepts the FCVS, it has its own VOT form with questions pertaining to professional knowledge, clinical judgment, relationship with patients, ethical/professional conduct, interest in work, and ability to communicate.

Hawaii had the most questions pertaining to performance during training: 9 questions concerning disciplinary actions and 4 questions regarding non-disciplinary actions.

Our study reveals wide inconsistency among the state medical licensing boards with respect to what PDs are asked regarding resident performance. The FSMB has attempted to standardize this process through the FCVS, which is accepted by 45 states and territories. However, only 10 states currently mandate use of the FCVS and an additional 33 states accept the FCVS in lieu of their own VOT forms. In addition, most states have their own VOT forms, which have a wide variability of questions. As a result, the information requested from PDs regarding trainee performance differs from state to state.

The primary focus of training programs is to ensure that residents achieve proficiency in the 6 core competencies as established by the ACGME. Our findings show that state licensing boards do not use these competencies to determine candidacy for licensure. Most states and territories ask about documentation of limitations or special requirements because of questions of academic incompetence, disciplinary problems, or any other reason. Based on individual interpretation by the PD, this question could lead to comments on a resident's deficiency in any of the competencies, but does not directly reference a resident's progression or failure to progress within the current physician training paradigm in the United States.

Most state medical licensing boards and the FCVS ask about disciplinary action. Only 1 state inquired directly about unprofessional conduct. Three states asked whether a patient or staff member filed a complaint against a resident. Papadakis and colleagues showed that physicians who were disciplined by state medical licensing boards were 3 times as likely to have behaved unprofessionally in medical school.⁴  Another study by Papadakis et al showed that poor performance on behavioral and cognitive measures during internal medicine residency were associated with a greater risk for state licensing board actions when in practice.⁵  To our knowledge, this is the only study to look at resident performance during training in relation to disciplinary actions by state medical licensing boards. There are no published data that specifically correlates disciplinary actions during residency with subsequent disciplinary actions by state medical licensing boards.

While most programs would likely utilize non-disciplinary actions to mitigate poor academic performance, licensing boards are not collecting this information, as our results show that only 7 states inquire about this. Non-disciplinary actions are typically used to address performance deficiencies and assist the trainee in achieving competency goals for graduation. While this may indicate that a resident has struggled at some point, it should not imply that a resident who required extra training, remediation, or additional resources should be disqualified from obtaining a license to practice medicine. We encountered 1 state (Nebraska) that asked if there was “any probation/remediation action?” While remediation is an action taken to improve resident performance, probation is a disciplinary action taken by the program or institution. This question may demonstrate a lack of understanding of the residency training process. It also demonstrates that there is a need for defining terms, such as remediation and probation, among all state medical licensing boards so that there is uniformity and consistency. This also raises concerns that inquiries regarding residents' academic performance and remediation may be used by medical state licensing boards to hinder or prevent the issuing of a medical license, even though upon graduation, the resident successfully has achieved all prescribed milestones.

A limitation of our study is that only information available online was evaluated. In addition, we limited our study to allopathic US graduates and excluded osteopathic and international graduates.

Future studies reviewing medical licensing board VOT forms for graduates from osteopathic and international medical schools and comparing the findings to those obtained in this study would be helpful in determining if there are significant differences in the questions asked about performance during those applicants' training.

There is marked variation among state medical licensing boards with regard to questions asked about resident academic performance. The majority of questions on VOT forms focus on disciplinary actions. Very few states ask about non-disciplinary actions related to academic performance and professionalism. Not a single state uses the ACGME 6 core competencies that programs routinely use to reflect resident performance in its VOT form.