AMA seeks clear path for doctors' re-entry into medicine

Fifteen years ago, Mark Greco, MD, an internist in Yardley, Pa., left clinical practice to work for the pharmaceutical industry because he became a single parent and needed a more regular schedule than he had as a critical care intensivist.

After working in private practice, Brian Gould, MD, a psychiatrist in Minneapolis, became an executive for hospitals and the health insurance industry for 25 years.

Ted Farmer, MD, an internist in Thomasville, Ga., closed his solo practice a decade ago to take care of his clinical depression.

Now they're coming back as clinicians.

They all have completed re-entry educational programs and are examples of an increasingly acknowledged phenomenon. They are physicians who leave clinical work to do anything from take a new job to take time with a new baby, then want to come back.

But coming back is not always easy. Relicensing requirements vary by state. Then there is figuring out how to get recertified. Doctors often have difficulty finding a local health system or a practice that is willing to take them in and help retrain them. The handful of formal re-entry programs can be expensive or inconveniently located.

"Physicians are often surprised that we can actually help them," said Nielufar Varjavand, MD, program director of the re-entry program at Drexel University College of Medicine in Philadelphia. "They are hitting closed doors left and right, either from the boards or from the employment agencies that tell them they have been away for too long. When they find us, they are thrilled that we exist."

To bring clarity to the process, the American Medical Association, in collaboration with the Federation of State Medical Boards and the American Academy of Pediatrics, issued recommendations on Jan. 25 calling for a comprehensive and transparent regulatory process for physicians to come back to medicine. The organization wants policies ensuring that re-entry programs are of high quality and that physicians who complete them are ready to practice.

Re-entry could alleviate shortage

The action was taken in part because physician re-entry may be one way to address the need for doctors, which is expected to get more acute when more people become insured as health system reform rolls out. It's unclear how many physicians would come back to medicine if the process were more straightforward, although the AMA estimates that as many as 10,000 could do so annually.

"It's a lot less expensive to retrain a physician than to make a new physician," said Michael Sheppa, MD, associate medical director of the North Carolina Medical Board. "Re-entry physicians have been through medical school. They have been through a residency. A lot of money has already been invested in them. To get these physicians back up to speed requires a lot less of a financial investment." The North Carolina Medical Board is one of the few with its own formal re-entry program.

The AMA, at its 2010 Interim House of Delegates Meeting, hosted an educational session on physician re-entry. Another session is planned for the AMA's 2011 Annual Meeting. The AAP and the FSMB have their own programs and publications on the issue.

The goal of these efforts is to balance the need for physicians to be able to re-enter clinical medicine with the need to ensure that those who do are going to provide excellent care.

"Our first concern is not the doctor, but the patients. The physician should be sharp and up-to-date," said Joseph L. Murphy, MD, chair of the AMA Senior Physicians Group Governing Council.

But at the moment, physicians who are working to get back up to speed and want to re-enter medicine find that the way is far from clear.

Dr. Farmer needed to get relicensed and found the process so complicated that he hired an attorney. He completed a program at the University of Florida College of Medicine in Gainesville, has his medical license again and is working to get his board certification back.

"It's been a long road," said Dr. Farmer, who started the application process about three years ago. "It's not over yet, but I can see the end of the tunnel."

Dr. Greco, who went through the re-entry program at Drexel, is working part time in patient education and looking for a clinical position. But he is concerned that people may doubt his skills and knowledge.

Dr. Gould completed a program with the Center for Personalized Education for Physicians in Denver. But he said he had a hard time finding institutions where he could receive the supervision he needed to get back his license. Facilities didn't seem to know what to do with him, or didn't know how he would fit in because he was neither a resident in training nor a fully credentialed physician. Now that he has his license, getting work has not been a problem.

"It should not have been so hard to find a clinical environment that would allow me to be retrained, but physicians in this position are neither fish nor fowl," Dr. Gould said. "We're not residents, and we're not practicing physicians. But now even insurance companies make referrals to me." He is a staff physician at the Courage Center in Minneapolis and the Psych Recovery Center in St. Paul.

Keep your license active

In the absence of consistent relicensure regulations, experts said, physicians should think about a possible return when leaving.

"Unless you are absolutely sure that you are never going to go back into clinical medicine, do not give up your medical license," said Bohn Allen, MD, a general surgeon who recently came out of retirement to become the physician director of the outpatient surgery clinic at John Peter Smith Hospital in Fort Worth, Texas. "Keep your CME up if there is just an outside chance that you may at some point want to go back to practice." Dr. Allen, a member of the AMA's Senior Physicians Group Governing Council, said he did just those things after his retirement.

But this is not always feasible. Dr. Gould didn't think he would ever practice again. Dr. Farmer said he was too sick to maintain his license. "If I had been thinking logically, I would not have let my license lapse," he said.

But even if just jumping back into practice were possible, several physicians said they would have completed re-entry education programs anyway. The programs usually involve an assessment of skills and knowledge and a plan to address anything that may be lacking.

"The re-entry program helped me a lot," Dr. Greco said. "I know I can do this. I really know the material. It was definitely worth it for me."

Physicians who have re-entered say that although the transition period can take longer than anticipated and be very challenging, it is possible and even desirable. There are many reasons a physician would want to return to clinical work after an extended absence, but those who have done so successfully say a love of medicine is the greatest driver.

"The idea of being in practice has more appeal in my early 60s than it did in my 40s," Dr. Gould said. "Then, I wanted to be in the business world. Now, seeing patients again is rewarding in ways that I had not anticipated."