It's Academic: November 2013


Should Texas Medical Licensing Laws Continue to Include Testing Limits?

TMA's Council on Medical Education is examining whether Texas medical licensing laws should continue to set testing limits. The council is considering whether to recommend new policy to the TMA House of Delegates and would value your feedback. Such policy would be used whenever TMA is called upon to recommend a position on proposed legislation that would alter the current requirements.

Take our survey here.

It is common for state legislation to be filed each session that seeks to add new exceptions to the state's three-attempt limit, as well as the seven-year maximum limit for passing exams accepted for Texas licensure. And, it also is common for TMA to be asked to advise legislators on what position they should take on such legislation. Usually the legislation is designed around the test results for a single physician who is unable to meet state licensing laws. The medical education council in the past has determined that three attempts is sufficient and questioned the necessity of writing laws just for one physician.

In the 2013 legislative session, several bills would have further eased these requirements with new exceptions. Only one bill with new exceptions passed. Of the bills that did not pass, Senate Bill 580 would have raised the attempt limit to five for each test component and a collective total of nine attempts for all exam parts. Senate Bill 1744 and House Bill 1482 would have increased the passage limits to five for license applicants who are licensed and are in good standing for at least five years in another state and who are board certified and make a commitment to practice for three years in an underserved area. Similar bills were filed in prior legislative sessions

Generally, Texas law requires passage of exams accepted for Texas licensure within three attempts. There are various exceptions. The three-attempt limit does not apply to:   

  • Applicants who are licensed physicians in good standing in another state for at least five years; AND 
  • Who passed all but one part of the exam within three attempts, AND: 


  • Passed the remaining part of the exam within one additional attempt; OR
  • Passed the remaining part of the exam within six attempts AND the applicant:
  • Is both board certified AND completed an additional two years of graduate medical education in this state.  

Tally of US States by Testing Attempt Limits
State laws on attempt limits vary for each Step of the United States Medical Licensing Exam (USMLE), as shown in the table below:

  Tally of US States by Testing Attempt Limits  

USMLE                   2           3*         4           5           6           NO Limit             Not Applicable                
Step 1      2     14   3     1     3     29  2  
Step 2      2     14   4     1     3     28  2  
Step 3      2     25    6     2     3     15 1  

*Texas generally has a limit of 3, with some exceptions, as described above. 
Source: "State Medical Licensing Requirements and Statistics, 2014" published by American Medical Association.

To summarize: 

  • Most states have NO limits for Step 1 and Step 2 – 29 and 28, respectively. But for Step 3, only 15 states have NO limits. 
  • For Steps 1 and 2, the second most common limit is "3," which generally matches the law in Texas, with some exceptions. 
  • For Step 3, the highest number of states, 25, have a limit of 3, as does Texas, with some exceptions. 

Testing Time Limits in Texas Law 
Texas law generally requires the passage of exams accepted for licensure within seven years. Using USMLE as an example, this means the clock starts when Step 1 is taken and ends with the passage of Step 3. There are the following exceptions to the limit: 

  • MD/PhD or DO/PhD physicians are allowed two additional years after completion of graduate medical education to complete a testing series. 
  • The time limit is extended from seven to 10 years if the physician is specialty board certified. 
  • Legislation passed this year (SB 949) removes the time limit for applicants who are licensed and a physician in good standing in another state for at least five years who also make a commitment to practice in an underserved area, as defined by the Texas Medical Board.
  • Physicians with faculty temporary licenses have special provisions for the time limit.  

(Note: this is a general summary of relevant state laws and rules, detailed information is available at:

Tally of US States for Selected Testing Time Limits
Laws on testing time limits vary by state, as summarized in the table below:

Tally of US States by Testing Time Limits, for Selected Time Periods Only
7 Years                             10 Years                             NO Time Limit               
18 states   10 states   17 states  

*Texas generally has a limit of 7 years, with some exceptions as described above. 
Source: "State Medical Licensing Requirements and Statistics, 2014" published by American Medical Association.
The greatest number of states (18) allow up to seven years to complete exams accepted for licensure. The second highest number of states (17) have NO time limit. Ten states allow 10 years to complete the series. Texas generally sets a limit of seven years overall, with two additional years for MD-, DO-PhD degree holders and other exceptions described above.
For the USMLE, the National Board of Medical Examiners shows a high passage rate on the first testing attempt, ranging from 94 to 97 percent, as provided in the table below. Those who repeat the exam have lower passage rates overall. The differences in passage rates are most significant for Steps 1 and 3. 

USMLE Passage Rates, 2012 

USMLE      Passage on 1st Attempt                Repeaters                                                                         
Step 1   94%   Both MD and DOs 68%
Step 2 Clinical Knowledge                       97%   MD 72%          DO 53%  
Step 2 Clinical Skills   97%   MD 92% DO Only 1 Repeater
Step 3   95%   MD 69% DO -0- Repeaters

Source: National Board of Medical Examiners 2012 Annual Report 

The National Board of Medical Examiners instituted a six-attempt limit for the USMLE on Jan. 1, 2013. Prior to that, there was no limit set by the board.

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Texas Largely Disadvantaged in Medicare GME Funding

The federal government provides more than $10 billion each year for graduate medical education through the Medicare program. "The Geography of Graduate Medical Education: Imbalances Signal Need for New Distribution Policies," published in Health Affairs, November 2013, draws attention to striking geographic disparities in the distribution of these funds. Given the strong relationship between where a physician trains and entry into practice, there are concerns about "distributional fairness in this form of public funding." 

Although populations are growing faster in the South and West, states in the Northeast garner the highest amounts of federal GME funding by a wide margin. New York tops the list at $2 billion (about 20 percent of all funds), with more residents in training than 31 other states combined. After New York - Massachusetts, Rhode Island, Pennsylvania, Michigan, and Connecticut lead the nation. Residency education in the US started in the Northeast and these programs have substantial training capacity. They are described as being well positioned to take full advantage of Medicare GME funding when this program was first established. Further, Medicare funding caps imposed in 1997 have "frozen in place a very irregular geography" in the allocation of funding. 

Texas ranked 35th in the Medicare GME funding cap per population at 18.19, based on 2010 data. New York ranked second at 77.13, behind the District of Columbia which has quite a small population in relation to number of residents. The US average was 29.31.

Total Medicare GME funding for Texas was $290 million in 2010, and the average Medicare GME payment per resident was $65,496. In comparison, New York received $139,126 per resident, and the US total average was $112,642. 

The authors acknowledge a growing national call for reform of Medicare GME funding and make the case for thoughtful reconsideration of funding inequities on a geographic basis.

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India, Pakistan, and New York Produce Doctors for Texas

Three out of four of the state’s 3,594 newly licensed physicians in Fiscal Year 2013 graduated from medical schools outside Texas, as reported by the Texas Medical Board. Forty-three percent of this group are graduates of schools in other states or Canada, and 30 percent completed medical education in other countries. 

When we look more closely at medical school information for the new Texas physicians, India produced the largest number of physicians – 284. The next largest was The University of Texas Medical Branch at Galveston (UTMB), at 155, followed by New York at 150. When the top two foreign countries -- India and Pakistan -- are combined, the total reaches 399, close to the total for the top three Texas medical schools for the newly licensed: UTMB (155), The University of Texas Medical School at San Antonio (137), and The University of Texas Southwestern Medical Center, Dallas (134), which have a combined total of 426.  

New York had more graduates among the group than each Texas medical school except UTMB, and was only five physicians less than UTMB. The next largest state was Pennsylvania with 104, followed by: Illinois, 95; Louisiana, 90, and California, 80. Mexico had 65 physicians and Canada 10. 

Off-shore medical schools in the Caribbean had 128 graduates among the newly licensed. Two off-shore schools were responsible for 74 percent of these graduates: St. George's in Grenada with 50 physicians, and Ross University in Dominica with 44. 

Doctors Want to Practice in Texas
As further evidence that Texas is an attractive place to practice, Texas ranked third in a ranking of states where 2013 US medical graduates plan to practice, according to the 2013 Association of American Medical Colleges' Medical School Graduation Questionnaire. The top two choices were California and New York.  

In 2012, the most current year for which data are available, Texas reached an all-time high of 182.6 direct patient care physicians per 100,000 population, per AAMC.

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Academic Physicians: Get the Credit You're Due

The TMA Award for Excellence in Academic Medicine recognizes teaching physicians who are clinicians and have a record of TMA leadership, scholarly activity, mentoring, professional development, advocacy, and community service. If this sounds like you, TMA encourages you to apply for this award program created for doctors like you. 

"TMA is eager to recognize our physicians who are consummate teachers, role models, and medical professionals," said David P. Wright, MD, chair of the TMA Council on Medical Education. "These awards underscore their value in preparing the future physician workforce and as leaders within TMA and their communities." 

The program has four recognition levels, Bronze, Silver, Gold, and Platinum. Eligibility criteria increase for each level. The criteria have been simplified from the initial version in 2012 in response to your feedback. We encourage you to take a look. Bronze, Silver, and Gold levels are self-nominating, and all who meet the criteria will receive recognition. A selection committee of TMA member physicians chooses the sole Platinum-level winner each year from among Gold-level recipients. Gold recipients remain eligible for the annual Platinum award for three years, with no need to reapply during that period. 

All award recipients receive a printed certificate and recognition by the TMA Council on Medical Education and Subcommittee for Academic Physicians at that year's TexMed. The Platinum winner also receives a $5,000 cash award. The 2012 Platinum cash award for Kenneth Mattox, MD, was generously provided by the TMA Foundation. All award recipients are recognized inTexas Medicine; in this newsletter, It's Academic; and in the Handbook for Delegates at TexMed, the TMA House of Delegates' annual meeting. 

Physicians may download applications through Dec. 6 at The deadline for submission to TMA is 5 pm CST, Dec. 6, 2013. 

If you have questions, email Jennifer McHaney at TMA or call her at (800) 880-1300, ext. 1451, or (512) 370-1451.

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Walk the Walk

Ready to practice what you preach? TMA's Walk with a Doc program is part of a national grassroots movement devoted to encouraging healthy physical activity. We want to reverse the consequences of a sedentary lifestyle and improve the health and well-being of our state, and we want your help.

The program has a proven track record of helping people commit to a healthy lifestyle through monthly, physician-led walks throughout the community. Strengthen your trusted leader role in your community and participate in a healthy activity with your patients. 

Walk With a Doc in Texas is promoted by TMA's Council on Health Promotion and funded by a grant from the TMA Foundation with major support from the Aetna Foundation. The council is specifically seeking TMA member physician walk leaders who practice in underserved areas of Austin, Dallas, Houston, and San Antonio.

Join the movement and get moving with your patients. Contact Debra Heater in TMA's Division of Communication for more information.

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 Join or Renew TMA Today: We Could Use Your Help!

TMA has been a longtime advocate for academic faculty and medical schools — monitoring legislation, determining the potential impact on patients, and lobbying for your interests.

The results of the 2013 legislative session were outstanding for academic medicine. Our efforts in this legislative session, including public testimony provided by TMA leadership at every applicable legislative committee hearing and personal visits with legislative members and staff, paid off. For example, lawmakers restored GME formula funding, which took a 31-percent hit in 2011, with a 15-percent, or $8.8 million, increase this budget cycle. Lawmakers also restored the Family Medicine Residency and State Physician Loan Repayment programs, which were almost eliminated in the past budget. Medical education also received a boost of 7 percent in per-student funding. TMA  helped stop off-shore medical schools from buying up clerkship spots in Texas hospitals and repealed a 2011 law that forced international medical graduates to spend three years working in only medically underserved areas. 
TMA is extremely successful in Texas — for one reason only. TMA speaks with one strong, firm, and consistent voice, the voice of its members. Only with grassroots support … only with your support … can we continue to be successful.  

Join or renew today at and see what a difference TMA membership can make. Within your department and/or academic institution, funds may be available to cover the cost of your membership. Please check with your department administrator or chair to see if applicable. 

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New-to-Texas Physicians Can Start Here

Are you a new Texas physician? Have you recruited a physician for your school, your practice, or your community from out of state?

 TMA's New to Texas webpage can help new or returning Texans get their practices up and running. The page provides links that doctors need to obtain a Texas license, plus contact information for relevant state and federal agencies, and links to resources such as practice consulting for set-ups, health insurance plan contacts, and employee salary data.

TMA members can email the TMA Knowledge Center or call (800) 880-7955 for fast answers to questions about membership, TMA member benefits and services, practice management or legal information, and more.

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This Month in Texas Medicine

The November issue of Texas Medicine tells you about plans for expanding graduate medical education. You'll also learn why physicians are glad the legislature restored funding for women's health, but say problems still exist, why TMA is challenging a CIGNA policy, what physicians say needs to be done about the state's antiquated mental health hold law, and what state and federal law says about communicating with patients.

It's Academic is for physicians in academic settings. For more information about TMA’s efforts on behalf of medical education and academic physicians, visit the TMA Council on Medical Education’s Subcommittee for Academic Physicians page on the TMA website.

Please share with your colleagues who are not TMA members and ask them to join.

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