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Tuesday, March 8, 2011

Mission Impossible: getting a medical license in California

I first applied for a license to practice medicine in the state of California on July 9, 2008. I was licensed on March 3, 2011, a whopping 967 days after they first received my application. I haven't had a problem getting a license in any other state, and I am licensed in six of them. Just to give you a sense of how long it usually takes to process the paperwork for a medical license, Maryland completed mine in under three weeks. So what's going on in California?

I think the best way to tell this story is with a timeline, and let the facts speak for themselves. I know this represents just one physician's experience (namely mine), so results may vary:

Image by Val Jones, MDJuly 9, 2008--The Medical Board of California (MBC) received my licensure application and my checks for $493 (for fingerprint and processing fee) and $805 (initial licensing fee), which were cashed soon thereafter.

Sept 29, 2008--I received a letter in the mail stating that there were four items missing from my application. Two of these four items were already included in the Federation Credentials Verification Service (FCVS) packet they had received from me. The other two items were requests for residency program directors to write letters to support the forms that they had already filled out on my behalf. I immediately requested these letters, and even though I should not have needed to send additional copies of items from the FCVS packet, I did so as well.

December 3, 2008--I received a letter in the mail from the MBC, stating that there was an additional fee of $25 now required for physicians whose licensure applications were postmarked after Dec. 31, 2008. This obviously didn't relate to me, but the letter reminded me to follow up with the board to make sure that they had received the four items from the Sept. 29 letter. I sent the licensing program administrator an email and left a voice message for follow-up purposes. He gave no response.

January 1, 2009 to September 30, 2009--I sent five different email requests for follow up information, without response from anyone at the MBC. I decided not to move to California, but to remain in Washington, D.C.

October 5, 2009--I sat next to an attorney on a flight to San Francisco whose law firm specializes in helping physicians get medical licenses in California. I told him that I was having a difficult time communicating with the MBC, and that they wouldn't even tell me what was missing in my application so that I could rectify it. The attorney told me that lack of communication with the MBC was extremely common, and in fact a large portion of his practice was devoted solely to suing the MBC to get them to process application paperwork. He asked me if I'd like to retain his services, and I said that it would cost too much and that I'd simply keep trying on my own.

October, 2009 to November, 2010--Every few months I sent an inquiry email about my application status, without any response from the MBC.

November 29, 2010--The first email response from the MBC arrived, stating that the only remaining item to complete my license application was a "delegation letter" from one of my residency training programs. I immediately asked for this letter from my program, and they explained that they had no idea what a "delegation letter" was. So I asked for clarification from the MBC.

November 30, 2010--The licensing technician (LT) assigned to applicants with last names beginning with "J" clarified that he needed evidence that the physician who signed my intern year training form had the authority to do so. (The residency program director was to "delegate authority" to the signatory.) As it happened, the department chair had signed the form instead of the residency program director. In essence, the residency program director needed to vouch for her superior. The delegation letter was mailed within two business days.

December, 2010--Repeated email requests for confirmation of receipt of the delegation letter, as well as assurance that nothing remained outstanding in my application, received no response.

January 26, 2011--I received an email from the MBC stating that a new LT had been assigned to my case and that she'd be reviewing my application for completeness. She found three items missing: 1) the delegation letter 2) a letter from my medical school registrar, vouching for a line item listed on my transcript, and 3) a new application form with new photo (because so much time had elapsed that they weren't sure that the application was still current). I responded that the delegation letter had been sent (I confirmed this with the residency program), that there was no one at my medical school's registrar's office who knew how to provide any additional assurance of my curriculum beyond the previously notarized signature of the Registrar herself (which was also verified by FCVS), and that I'd be happy to fill out the application form and provide a new passport photo due to the excessive time lapse.

January 28, 2011--The new LT emailed me to say that she had met with "senior staff" about my application and that there was no record of receipt of a delegation letter, and that I needed to get my former residency program director to again write them a letter that the chairman of the department has the authority to sign my application form. She also said that the senior staff had relented regarding the authorization letter from the registrar's office.

February 2, 2011--I was cc'd on an e-mail from my former residency program confirming that the delegation letter had been faxed on Dec. 2, 2010, and a copy had been mailed to MBC on that date, as well as a second copy on Feb. 2 and an e-mail attachment directly from the residency program director.

February 8, 2011--The LT informed me via email that the new application that I provided (along with my photo) had the notary's signature in the incorrect location, and that I needed to provide a re-notarized copy of the application. I asked if another photo was needed.

February 9, 2011--The LT informed me that a third photo was not needed, and that she could peel the last one off the new application and affix it to the third (and newly notarized) copy of the application form. I was worried that the older photo would be lost, so I got a third passport photo made anyway, and attached it to a new form that I got notarized by another person.

February 21, 2011--I requested email confirmation of the newly notarized application form (a U.S. Postal Service Delivery Confirmation Receipt showed delivery on Feb. 11). No response offered.

March 3, 2011--I again requested e-mail confirmation of the completion of my application.

March 3, 2011 (3:49 p.m.)--I received this e-mail response from the LT: "Congratulations! You are now a licensed physician with the State of California. You can access your license number off our web site. It was nice working with you."

And that's how I became a licensed physician in the state of California. Of course, the clinical job I was interested in in 2008--for which I'd originally applied for a California license--is now long gone, life has moved on, and I just bought a house on the beach in South Carolina.

So if you live in California and are having a hard time finding a doctor, perhaps it's because physicians like me are being effectively prevented from working in your state by its own medical board? I bet you hadn't thought of that.

This post by Val Jones, MD, appeared at Get Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.

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1 Comments:

Anonymous Anonymous said...

I am applying for a California medical license now. Very worried as it is September 2011 and I am looking to start working in July 2012. I have 3 state licenses so far without problem. Also, I noticed nowhere on the application forms (at least the revised 03/11 version) does it say explicitly whom and where to mail the application to, so I'm not sure who my medical schools, residency, and state licensing boards should address their communication too. Seems like an important thing.

September 26, 2011 at 10:31 PM  

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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