On June 9, 2015, Steven J. Stack, MD, FACEP, was sworn in as President of the American Medical Association (AMA). Dr. Stack recently spoke with ACEP Now Medical Editor-in-Chief Kevin Klauer, DO, EJD, FACEP, about the licensing and certification challenges facing emergency physicians.

Check out the May issue of ACEP Now or visit ACEPNow to read the first part of this conversation.

Dr. Kevin Klauer: I’m hearing a lot of discontent from physicians regarding licensure and being able to get licensed from one state to another. The Federation of State Medical Boards (FSMB) is looking at this, and its interstate licensure compact makes a lot of sense. How does the AMA feel? Should this be a national process or state-by-state determination of participation?

Dr. Steven Stack: This is one of the joys of our federal system of government, right? It’s a state’s rights kind of issue, and at the highest level, the AMA has policy that opposes national licensure and that supports state-based licensure. Part of the premise is that this is one of the ways where the states are accountable for the safety and well-being of their citizens. State-based licensure is the way we license all professions, and so that’s not going away anytime soon.

As far as the complexity, burden, and lack of coordination across states, that has to be fixed, and there’s no reason in the modern era with all the technology we have that it shouldn’t be fixed. To that point, we support the FSMB’s work on its compacting initiative, which would simplify and streamline being able to get additional licenses in other states. So if you have a primary license, which is your main or anchor license, there’d be an expedited process to apply for licenses in other states. You would still have to pay a fee, and you would still have to complete some paperwork, but through the compact, various agreed reciprocities between states that participate, and the use of the FSMB Federation Credentials Verification Service, a lot of that information can be prepopulated, streamlined, and simplified to lower the overall burden to physicians and the overall cost and still provide for state-based oversight for the practice of medicine. We’re very supportive of the work that the FSMB is doing and have tried to partner with state medical societies to advance it so that state legislatures and state boards adopt this quickly to make it easier for physicians and so that patients have better access to docs. With the growth in telemedicine and telehealth, there is a real need to get access to scarce services to more people, and telemedicine is going to be one of the ways that probably happens.

KK: Let’s discuss a related topic that is often a bit confusing for providers: Maintenance of Licensure (MOL). Some are wondering how it differs from Maintenance of Certification (MOC), but my specific question for you is regarding the frustration that docs have about MOC. Is this really a process that fosters quality of care, lifelong learning, and being a better, competent provider? Or is this just extra expense for providers and an intrusion into their practice?

The third and final thing is that we are working doggedly to improve physician professional satisfaction and practice sustainability. We are trying to find out about things that make doctors happy and things that make them sad and
frustrated.

SS: There’s a perception among the licensure and certifying boards that there is a need for the public to know and be reassured that their physicians are engaged in lifelong learning and self-assessment throughout their careers and that they’re achieving board certification. A license is not an anointment until death. It is one step in a journey that is your lifelong professional practice. Now, we can agree or disagree on whether that is the case, but it is their belief that the public is requiring this, and so they have moved forward with these different paradigms.

The board-certifying bodies are way out ahead, and the licensure boards are not, but the concern is that only 70 to 80 percent of physicians in the United States are board certified. This means that if you are licensed but not board certified, the assertion can be made that you have no expectation to demonstrate continuing competency because you’re not subject to a specialty board and its requirements. Once you get your license, a lot of times, as long as you send in your check, you get to keep it unless you get into trouble with the board. Some in the licensure community have said, “We have to come up with some way to address that part of the population that is not board certified.” So MOC does not equal MOL, nor does MOL equal MOC, but MOC, being a robust program to ensure the lifelong self-assessment and competency of physicians, certainly should stand in fulfillment of anything that would be required for MOL. They are very different programs, and MOL, I would say, is more intended to make sure there is some base floor of safety because licensure does not guarantee excellence, it only increases the likelihood of minimum competency. Board certification may directionally foster some aspect of

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excellence, but licensure is really about a minimum standard. It’s not about aspiring to great things. There are more than 70 licensing boards in the United States because there are some states that have separate boards for DOs and MDs, each one of which would have to ratify, for its own internal rulemaking or state lawmaking, a process for MOL. That’s going to take a long time. If some states are going to say, “Heck, we’re not doing that at all,” they may never do it. There are some states that are going to jump right in and want to do it. For MOC, that’s a big discussion.

The American Board of Medical Specialties (ABMS) created MOC, and they are physicians. This is not someone else—they are us. If people are upset, they need to communicate with them. The AMA has been engaged, and we have worked with the ABMS to say, “Look, these programs have to be responsive to the burden on physicians and the cost to physicians, they have to be based on evidence, and they have to be able to demonstrate they’re actually improving quality and making physicians safer or better. They can’t just be busy work without value.” We have partnered with the ABMS to try to have its overarching structure be more flexible and more tailorable to these specific specialties so the tools that can be developed make sense because each specialty has different needs.

Here’s an instance where I would say, “I’d love to think the AMA can solve everything for everybody,” but it can’t. This is fundamentally about specialty-certifying programs. This is a place where ACEP’s role is arguably far more impactful than what the AMA’s is. I just got back from California, where I spent the whole weekend with dermatologists, and they hate their board. Hate is not too strong. People were walking around with pins on, like little campaign buttons, made with the red circle and the slash that said, “No MOC.” The comments people made conveyed visceral disdain, disgust, and outrage at their board. Now, if it’s just one board, you can say it’s just one board, but you’re aware the American Board of Internal Medicine (ABIM) gave a mea culpa that was effusive. It was, “We’re sorry, we were wrong” repeated over and over in their communication to their diplomats. There’s a prominent group of internists, I’m not going to use names, many of whom are nationally known, who are creating their own board to directly compete with ABIM because they feel the ABIM’s program is so out of touch with reasonableness or demonstrated value to their profession or patients that they are going to try to compete with ABIM and offer an alternative. It’s a big deal; it’s a really, really big deal.

Hate is not too strong. People were walking around with pins on, like little campaign buttons, made with the red circle and the slash that said, “No MOC.”
–Steven J. Stack, MD, FACEP

There were a couple of articles published in the JAMA journals with evidence that says, “Hey, it doesn’t look like these programs actually improve quality or safety.” The boards would likely say they have their own evidence. Maybe they were the only ones doing research in the last few years so they have evidence, but now people are energized, and there will be other doctors who demonstrate their own evidence that may tell another story. I would say that emergency docs need to speak up, and they need to speak up strongly and to the extent they feel that their board is either assessing them reasonably or that it is unfairly burdening them and giving them busy work. ACEP and the other specialty societies are on point for this because, fundamentally, this is a specialty board issue. We [AMA] will be around to be supportive and be helpful, but the individual docs in the specialties will have to push on this one.

KK: I completely agree. It’s easy to look to the AMA for solutions and also to criticize the AMA when certain things don’t change, but it’s important to highlight the AMA can’t be responsible for everything, and it doesn’t have jurisdiction over all of these issues. Now a more broad-based question for you: on June 9 you were sworn in. What is the priority list for your year?

SS: The overarching response is that I will exist in service to the association. Steve Stack has no mission or agenda other than to ensure the success of the AMA, which is to help support our profession and the work we do for patients. That’s not a platitude; it’s real. I have no agenda. There is no Steve Stack theme. There is no, “I’m going to change the whole world to fit my image of it.” I’m going to give my very best as a practicing physician who still works days, nights, holidays, and weekends, just like other emergency docs. I’m going to give the best I can and use whatever experience I have to try to shine light on physician concerns in a way that is impactful and constructively received by policy makers and other leaders in society in the hope that we can work together to make things better for physicians in our profession and for patients.

Now, the AMA has a three-part strategic plan for people who might say, “Come on, seriously, what really are you trying to accomplish?” In addition to our enormously broad advocacy work and other things we do, we’re going to try to do three big things, and these are part of a 10-year plan.

First, and this is not rank ordered, we’re going to radically reform undergraduate medical education. Medical school has essentially the same structure it did 100 years ago when Abraham Flexner did his work and came up with a new model. It needs to be changed. We have new ways to teach, new ways to learn, new ways to assess, and a whole new collection of content—like business, finances, politics, population health, and legalities of medicine—that needs to be incorporated, which is not covered well in the current curriculum. However, you can’t just keep putting more stuff in the container. You have to change the whole shape and structure of the container so that you can do it differently. The AMA put $11 million in a five-year grant program that is working with 11 medical schools in the country in a consortium to radically pilot and reconceive a medical education. I hope that a decade after that work has begun, we’ll have a new model for medical education in the country that will serve the physicians of tomorrow better than the current model is serving them.

The second is to improve health outcomes for the nation by tackling big public health concerns. We are going to work on the proper diagnosis and effective treatment of hypertension. There are 70 million people in the country with hypertension and tens of millions of them who are either not diagnosed or not properly treated. They have preventable harm happen that we should not allow. The next is the diabetes epidemic. If we don’t fix that, we’re going to have an incredible burden of human illness and disease in our population, something that will be economically unsustainable and humanly intolerable. We know that if we institute lifestyle programs that sustainably alter people’s diet choices, exercise choices, and activity choices, we can profoundly reduce the number of people who are in a prediabetic state who convert to diabetes. We are working with the Centers for Disease Control and Prevention, the YMCA of the USA, and others to come up with ways that, on a national level, we can catalyze the change that we all know needs to happen.

The third and final thing is that we are working doggedly to improve physician professional satisfaction and practice sustainability. We are trying to find out about things that make doctors happy and things that make them sad and frustrated. If those things are either directly within our sphere of control as individual doctors or the AMA and/or within our sphere of strong influence, we can intervene and make life better for physicians. I think the profession feels a bit downtrodden and run-over right now, with everyone shouting at us to do what they want us to do and nobody really supporting us in what we need to do.