Testing the Limits

TMA Evaluates New Policy on Medical Licensing Tests

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Medical Education Feature — February 2014

Tex Med. 2014;110:(2):27-31. 

By Amy Lynn Sorrel
Associate Editor

Three tests, three chances per test, and a total of seven years. Those are the general rules and timeframes physicians must follow in passing the necessary exams to get licensed to practice medicine in Texas, most commonly the U.S. Medical Licensing Examination (USMLE).

Almost every legislative session, state lawmakers introduce a handful of bills to expand those limits, most of which fail. And almost every legislative session, lawmakers call upon the Texas Medical Association for advice on how they should weigh in on the legislation, which TMA typically shies away from.

The problem? The bills tend to be crafted around solving the needs of a single physician who can't meet current licensure laws, instead of solving Texas' overall need for a qualified physician workforce, says Temple oncologist Christian T. Cable, MD, a member of TMA's Council on Medical Education and director of the hematology/oncology fellowship at Baylor Scott & White Health. Three such bills surfaced in 2013 alone; one of them passed.

The other problem? "TMA doesn't have current policy on it," adds council member Rodney B. Young, MD, a family physician and chair of the Department of Family and Community Medicine at Texas Tech University Health Sciences Center in Amarillo. "If the legislature is in session, there are going to be efforts to amend these [testing limits]. And since this is a problem that won't go away until those seeking to amend the law are satisfied, we are always going to be asked for our opinion."

That is why the council is evaluating whether to recommend new policy for the TMA House of Delegates to consider in May. 

"What we want is to have a stable standard in place," Dr. Young said. The council recognizes that no test is perfect. Still, "while the USMLE is one measure of knowledge achievement, it is not designed to figure out who are the best doctors; it's designed to establish a minimum threshold of knowledge. We need doctors, and we want people to pass this test. But we have to make sure they have adequate knowledge and can demonstrate it in some way." 

Seeking a Stable Standard

Texas law generally gives physicians three chances to pass each of the three steps of the USMLE to get licensed, and they have seven years to do it. A few exceptions apply. For example, the time limit is extended to 10 years for physicians who are specialty board-certified, and doctors pursuing an additional PhD degree are given an extra two years to pass. 

More details on state licensure requirements is available on the TMA website

Over the years, the Texas Legislature attempted to carve out additional exceptions to Texas' licensure law. In 2013, Senate Bill 580 would have raised the attempt limit to five for each level of the licensing exam, with a cap of nine attempts for the entire exam. Senate Bill 1744 and its companion, House Bill 1482, would have increased that attempt limit to five for applicants who are licensed and in good standing for at least five years in another state, are board certified, and commit to practice for three years in an underserved area. The bills, which mimicked similar carve-outs from past legislative sessions, did not pass. 

Senate Bill 949, on the other hand, cleared the 2013 Legislature. The law gives out-of-state physicians willing to practice in an underserved area in Texas more time to pass the licensing exam. It removes the seven-year limit, provided the physician is in good standing in the other state and licensed there for at least five years.

Bill sponsor Rep. J.D. Sheffield, MD (R-Gatesville), says that as a rural family physician, he understands firsthand the shortages facing clinics and hospitals across the state, and SB 949 was part of an effort "to ensure that Texas can attract and retain qualified physicians for our rural and underserved areas. I am looking forward to continuing to work toward improved patient access to primary care physicians regardless of where a patient resides." 

But Dr. Cable worries the continual barrage of legislation could create a slippery slope of exceptions that erode what the council has long considered to be good law that ensures physicians are qualified to practice in Texas and maintains high quality-of-care standards.

TMA may not have policy yet to guide possible changes to Texas' licensure testing standards, but the association does have policy opposing different practice standards for different parts of the state. "We want to be confident someone is well-trained. And we want all residents of Texas to have qualified physicians. What's good enough for our rural areas should be good enough for Austin. We don't want to set up two standards of care in Texas," Dr. Cable said.   

Setting New Limits?

To inform the policymaking process, the council began by surveying members on whether, in fact, the current limits should be changed when it comes to attempts and time limits — the two areas that seem to be of greatest interest each time the issue comes up in the legislature. TMA was still collecting responses as this article went to press. You can take the survey online

Early results show most respondents agree that at least some parameters are necessary. While some find the current standards sufficient, others see room for improvement. But a small minority said that there should be no testing limits, calling the test irrelevant to physician competence. Those who favored changing the current limits generally preferred a slight increase in the number of attempts and/or time limits to pass the licensing exams. 

The council also is investigating other states' standards. According to American Medical Association data, Texas' rules are among the more rigorous in the country. Roughly 30 states have no attempt limits for steps 1 and 2 of the USMLE. Of the rest, most states, like Texas, allow three attempts per step. Fifteen states have no limits on Step 3, while 25, including Texas, have a cap of three attempts. 

States also vary on testing time limits: Seventeen states impose no timeframes to pass the license exams. The cutoff in 18 states, including Texas, is seven years. Ten states allow 10 years. For more resources on medical licensure, click here

Because Step 1 of the USMLE focuses heavily on the basic science foundations in medicine versus the clinical sciences practicing physicians use every day, some proponents of changing Texas' rules say it can be difficult for physicians from other countries or states who haven't taken that core science coursework in years to relearn the material to pass that part of the exam. For that reason, they have pushed for increasing the attempt limit from three to five attempts for Step 1 and even Step 2. 

Step 3, which most U.S. medical school graduates take during residency, focuses on the broader clinical knowledge doctors need to begin practicing what they've learned. "Since this step is more clinical in its focus and occurs later in training, there's an expectation that you should be able to [pass the test] in fewer attempts because by that point, you should have the material mastered and be able to apply it," Dr. Young said. 

The council believes Texas' basic rules serve the state well, and part of the process of evaluating possible changes means finding "evidence that the current system is somehow broken or unfair," he added. Having no limits to pass the test, however, is of no use. "The test is a minimum threshold. If you don't have a certain percentage that falls out, what's the point of the test? It's supposed to identify people at the lower end of the spectrum." 

Following Medical Schools' Lead

TMA leaders also say both TMA policy and state law should follow the lead of the state's medical schools. 

"As someone who evaluates candidates for residency, I'm not excited to see an application that says 'fail, fail, fail.' That does not bode well for someone's likely success in a program and should raise caution flags about fitness for practice," Dr. Young said. On the other hand, "I have had good residents with solid clinical performance, no evidence they were substandard, and terrible problems demonstrating that knowledge on standardized tests." 

That's where medical schools step up in their commitment to work with students to help them pass their exams, Dr. Cable says. But those same schools have a number of checks and balances to ensure they are graduating well-prepared doctors. 

Most Texas medical schools won't promote students from the second to third year of medical school if they have not passed Step 1 of the USMLE, and won't graduate them until they pass Step 2, he explained. Nor do most residency programs accept graduates until they've passed Step 2. Lastly, most graduate medical education [GME] programs won't advance students to a higher level of residency needed for board certification until residents pass Step 3. 

TMA leaders also pointed to National Board of Medical Examiners data that show high passage rates on the first testing attempt of the USMLE, ranging from 94 percent to 97 percent. Those who repeated the exam, however, had lower passage rates overall in the 60-percent to 70-percent range.

"If GME programs aren't even offering interviews [to students with lower passage rates], we [the council] feel that kind of thinking should have an influence on the quality of physicians in Texas," Dr. Cable said. He added that changing the medical license testing limits in Texas without taking that into consideration also could create a gap between state rules and medical school policies that harms students' chances of getting admitted to residency programs. 

Provisions that require out-of-state physicians to have a track record before getting licensed in Texas may make legislation like SB 949 more "palatable," he says. "But there have to be limits, and the [current] limits are reasonable and already being engaged by our training programs. We don't want to say this is what we expect from people who train here but then change things if you came from somewhere else." 

San Antonio family physician K. Ashok Kumar, MD, finds himself somewhere in the middle of the debate. As vice chair of medical student education in The University of Texas Health Science Center at San Antonio Department of Family Medicine, he, too, evaluates residency candidates and sees the value of having test standards. But as an international medical graduate (IMG), he also understands some of the extenuating circumstances these and other students face that could unintentionally cause Texas to lose qualified physicians to other states. 

The license exams are "definitely a good screening tool," he said, adding that students who attempt the test multiple times are viewed as weaker candidates. That doesn't always necessarily translate to being a bad doctor, "but we have to have some fundamental rules."

On the other hand, some IMGs, regardless of their test acuity, may find themselves waiting an extra one or two years to get admitted to a residency program if they are waiting on a visa, for example. "They might qualify for Step 1 and Step 2, but now that there is so much competition for residency slots, they are waiting to get taken into a residency program," Dr. Kumar explained. 

That means the clock is ticking to take Step 3 and get licensed to practice in Texas within the seven-year time limit. It also means Texas could lose those and other similarly situated physicians to other states in the meantime. "If there are exceptions where you can't come back to practice in Texas until you're licensed somewhere else for at least five years, what happens? They never come back," he said.

Dr. Cable says that the Council on Medical Education is working carefully to determine whether the tide is indeed changing. 

"We know that taking a multiple-choice test is imperfect and doesn't correlate well with who is a good doctor. And we don't want anyone banished from practicing in Texas. But what I don't think we should do is introduce a bill every session to address a particular doctor, in a particular location, in a particular scenario," Dr. Cable said. "With all those caveats, we are trying to come up with a reasonable standard that says we are confident physicians in Texas are well-trained."  

Amy Lynn Sorrel can be reached by telephone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email.   

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