The era of modern medicine in North American began after Abraham Flexner's 1910 report. In 1915 the National Board of Medical Examiners formed to develop and certify medical doctors. This group helped establish national certification exams (the United States Medical Licensing Examination or USMLE) based on the science-based curricula that sprouted from Flexner's work. Passing the USMLE is only one hoop today's physicians must jump through to practice in North America.
Regulation of medical licensure falls to State Medical Boards, all of which require some sort of examination. While some acceptable alternatives exist, all 50 states accept passage of the USMLE. This examination actually includes 4 separate tests of a physician's competence.
- Step 1 covers the basic sciences important for the practice of medicine in a multiple choice format. Medical students in traditional programs take this test at the end of their second year.
- Step 2 consists of 2CK (for clinical knowledge) and 2CS (for clinical skills). 2CK is another multiple choice exam; for 2CS students must travel to testing centers where examiners observe each student taking a history and performing a physical exam on a standard patient (an "actor" trained to present with specific symptoms and findings). For 2CS the student also must demonstrate the ability to synthesize findings and create a plan for diagnosis or treatment that they successfully communicate to the standard patient. Students in the fourth year of a traditional curriculum take the portions of Step 2.
- Step 3 returns to the multiple choice format, but focuses it questions on patient management. This step is taken after successful completion of the medical degree.
Once a doctor passes all components of the USMLE, they are eligible for medical licensing in North America.
Regulating medical practice belongs to state governments, and requirements vary from state-to-state. Most states will grant a full, unrestricted license after passage of all 3 steps of USMLE plus 1-2 years of post-graduate training. Historically, the first year after medical school was a rotating internship; completion of that year would allow one to be a general practitioner or GP. Family Medicine, officially recognized in 1969, has essentially replaced general practice in the US. Physicians practicing family medicine complete 3 years of post-graduate training and can be board certified in their specialty.
Licenses must be renewed periodically. After some set time period each state assesses a physician's practice record (have there been any complaints or crimes?), and most require some documentation of attendance at continuing education programs.
Specialty board certification occurs after completion of an approved training program. Upon completion of a residency or fellowship, a physician becomes Board Eligible (BE). After demonstrating an unrestricted medical license, certificate from a training program, and the ability to write a really large check, BE physicians take another test focusing on their specialty. For us sub-specialists, the process happens twice! First we must become board certified in our primary specialty (Pediatrics in my case, Internal Medicine in others). Then, after appropriate fellowship training, we get to take another exam for our new skill set.
Specialists tested before 1984 generally have life-long board certification. Those of us examined after that date have time-limited certification; we get re-examined every few years. In the last 5 years, the Boards have moved from a testing focus to Maintenance of Certification (MOC). Continuing education, practice improvement, and testing are all components of MOC.
One has to have a valid, unrestricted medical license to qualify for MOC. Continuing education is a requirement for that license in most states, and some MOC requirements can be used to meet this component for licensing. MOC is not (yet) required for a medical license or to practice a specialty in the US. Board Certification is generally required for practice in academia, and rumors abound suggesting that medical insurers may eventually require MOC for payment of specialists. The American Society of Nephrology has worked closely with the American Board of Internal Medicine to develop MOC-friendly offerings; more information about this process for (adult) nephrologists can be found here.
Some images in this post are used courtesy of PhotoXpress.