Passing all stages of USMLE allows me to do what?

[gingernrum]

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Hi,
I am curious about what someone who has passed all the stages of the USMLE but hasnt completed a formal residency is allowed to do. They are "licensed" but in what? What scope of practice could they have? What are they not allowed to do? Can they prescribe med?

For example, an oral surgeon who is both an MD and DDS likely will have the USMLE's passed even though the MD component isnt required for their board certification. What would the scope of their "medical" practice?

 

[dragonfly99]

No they would not/could not be licensed in any state.
Therefore, without any residency they cannot do any unsupervised clinical activity (because they cannot get a license).

All states require at least one year of GME (so, at least an internship), and some states require more, in order to be able to get a license. All states also require that you pass USMLE Step 1 2 and 3 to get your license. If you are a FMG, you have to finish your entire residency before you can get an unrestricted medical license.

 

[tkim]

http://www.fsmb.org/usmle_eliinitial.html

The minimum is 6 months for teh Virgin Islands, otherwise it's at least a year before you can be licensed.

 

[Pilot Doc]

Tagging on a bit, passing a 3 steps is a prereq to an unrestricted license, the other requirement is graduating from med school and finishing an internship.

At that point (when you get a DEA number) you legally can do EVERYTHING. You can presrcibe narcs, you can do liver transplants, you can do chemotherapy and psychotherapy. Whether anyone will let you use their hospital for said purpose or whether you will be paid is another issue. But and unrestricted physician and surgeon's license is just that - unrestricted.

 

[docB]

Hi,
I am curious about what someone who has passed all the stages of the USMLE but hasnt completed a formal residency is allowed to do. They are "licensed" but in what? What scope of practice could they have? What are they not allowed to do? Can they prescribe med?

For example, an oral surgeon who is both an MD and DDS likely will have the USMLE's passed even though the MD component isnt required for their board certification. What would the scope of their "medical" practice?

Completing the USMLE steps does not make you licensed. As previously mentioned it is a prerequisite for applying for licensure. Each individual state has its own requirements such a years of residency (in NV it's 3 years of residency), criminal background check and so on. If you don't meet any one of them you don't get licensed.

As for what you can do with a license but no residency training or board certification the answer is that legally you can do anything but practically you can't do much. You will find it hard to get credentialed by hospitals and reimbursed by insurance companies. Check out any of the many "What can I do with no residency?" threads in this forum.

 

[gingernrum]

So from what I understand, after, for example, completing 1 year of general surgery residency and passing all stages of the USMLE you are technically allowed to practice and do what you want almost but there are major obstacles in terms of getting paid. I take it you can do things like surgical assist and moonlight in the ER and get paid?

 

[dragonfly99]

I doubt that any ER would hire someone with only an internship to be an "attending" in an ER. That isn't really enough experience, and they would be taking a huge liability risk. Our VA will hire folks who haven't necessarily taken or passed boards yet, but you have to have finished residency (either ER or IM) to moonlight there. Local urgent care centers occasionally hire IM fellows from our hospital to moonlight, but pay them less than they would a normal attending (kind of a ripoff....) but they don't hire anyone with less than a full residency (at least in my city/area).

There might be some places that are desperate that would hire someone to work in an ER with only an internship...I don't know. Remember, the hospital or urgent care facility has to get paid, too in order to pay you (assuming it's a private hospital or clinic) and many (? probably most) insurance companies will not pay/reimburse for someone's care unless the person has completed a residency. Some insurance plans will not pay unless the doc is board certified. An urgent care or ER can hire a PA or NP to assist, who is "board certified" and considered fully qualified, while a physician with a license but no completed residency or board certification is considered incompletely trained.

 

[Doctodd]

sounds like you want to start up a website to treat patients and prescribe meds???

 

[MR1]

I doubt that any ER would hire someone with only an internship to be an "attending" in an ER. That isn't really enough experience, and they would be taking a huge liability risk. Our VA will hire folks who haven't necessarily taken or passed boards yet, but you have to have finished residency (either ER or IM) to moonlight there. Local urgent care centers occasionally hire IM fellows from our hospital to moonlight, but pay them less than they would a normal attending (kind of a ripoff....) but they don't hire anyone with less than a full residency (at least in my city/area).

There might be some places that are desperate that would hire someone to work in an ER with only an internship...I don't know. Remember, the hospital or urgent care facility has to get paid, too in order to pay you (assuming it's a private hospital or clinic) and many (? probably most) insurance companies will not pay/reimburse for someone's care unless the person has completed a residency. Some insurance plans will not pay unless the doc is board certified. An urgent care or ER can hire a PA or NP to assist, who is "board certified" and considered fully qualified, while a physician with a license but no completed residency or board certification is considered incompletely trained.

It really depends on where you are, in my state (which is rural) there ALOT of ER's that would hire a dermatologist or radiologist (real examples) to work in them. Granted they are very low acuity and low volume. Do I think this is a good idea, no, but it happens alot. Urgent care clinics are the same way. About insurance, you can get on medicare and medicaid no problem with just a license and no BE\BC. Most of the other insurances will only pay out of network for you, but they still pay.

 

[badasshairday]

Passing all stages of USMLE allows you to practice medicine... and get sued and lose the case easily if you are not board certified.

 

[dragonfly99]

Passing all stages of USMLE allows you to practice medicine...

Not unless you have a license. And there is more to getting a license than passing the USMLE. You have to get fingerprints, a background check, usually some reference(s) from colleagues or a program director type, and have a certain number of years of residency (as mentioned above by different people, the amount of residency that must be done before getting a medical license seems to vary by state).

 

[Winged Scapula]

RE: Surgical Assisting

There are a variety of training paths to getting credentialed as a surgical first assist: RNFA, CSA, PA and MD/DO.

I have been told that Medicare is now refusing to pay for surgical assists who are not physicians, nurses or PA (ie, not CSAs). Whether or not this will filter down to other insurers, is another story.

As an MD, you may be asked to be Board Eligible to be first assist. I have a friend who never took her surgical boards and is no longer BE and decided to take time off from her practice and just do surgical assisting. One local hospital turned her down for credentialing because she was not BE. Doing a single year of internship does not make you BE. There must be a way around it as I have another FA who never finished residency and as far as I know, he gets paid and has credentials. It likely varies with hospitals.

Finally, a single prelim surgical year may not get you enough surgical experience to get a job with a surgical assisting firm. You will likely operate very little and will have no Ortho experience or other subspecialties. Without the capabilities to assist in a variety of specialties, you may not be very useful to a company to hire.

So before you assume that you can work as a surgical assist, contact some hospitals and see what they require to be credentialed and some surgical assisting companies and see what they require to hire you.

 

[core0]

RE: Surgical Assisting

There are a variety of training paths to getting credentialed as a surgical first assist: RNFA, CSA, PA and MD/DO.

I have been told that Medicare is now refusing to pay for surgical assists who are not physicians, nurses or PA (ie, not CSAs). Whether or not this will filter down to other insurers, is another story.

As an MD, you may be asked to be Board Eligible to be first assist. I have a friend who never took her surgical boards and is no longer BE and decided to take time off from her practice and just do surgical assisting. One local hospital turned her down for credentialing because she was not BE. Doing a single year of internship does not make you BE. There must be a way around it as I have another FA who never finished residency and as far as I know, he gets paid and has credentials. It likely varies with hospitals.

Finally, a single prelim surgical year may not get you enough surgical experience to get a job with a surgical assisting firm. You will likely operate very little and will have no Ortho experience or other subspecialties. Without the capabilities to assist in a variety of specialties, you may not be very useful to a company to hire.

So before you assume that you can work as a surgical assist, contact some hospitals and see what they require to be credentialed and some surgical assisting companies and see what they require to hire you.

Medicare will reimburse physicians, PAs, NPs, CNS (in some states) and CNM for first assist, its been this way for a while. It gets interesting since RNFAs claim to be APNs in the OR but aren't recognized as APNs by states or Medicare and hence are not eligible for reimbursement. Medicare looked at adding RNFAs and CFAs for reimbursement but somehow during the process they decided all first assists worked for hospitals and that all the reimbursement should go to hospitals. Eventually the whole thing was given up as a bad job.

The interesting thing about First assisting is that as a physician you might be better off if you are not licensed. If you are an unlicensed physician then you will not come under the medical staff rules for physicians (ie BE/BC). On the other hand if you are not licensed then you are not eligible for Medicare. Kind of a catch 22. I would agree that someone might have a hard time getting on with a first assist company, but if you find a sympathetic surgeon they might be willing to train. Its much the same issue with privileges. It largely depends on how much the surgeon is willing to advocate and how much pull they have.

David Carpenter, PA-C

 

[Winged Scapula]

Medicare will reimburse physicians, PAs, NPs, CNS (in some states) and CNM for first assist, its been this way for a while.

Perhaps that is true in some states.

But recently the surgical assist group I've been using has had to request information about insurance billing up front, because they have not been paid for several Medicare cases. They claim its because Medicare will not pay for CSAs, only PAs, RNFAs, and MDs/DOs. Just today, the guy who was sent over had to call a colleague to come and replace him when he found it was a Medicare case. I haven't investigated it further, just took their word for it. They recommended I use MDs for my Medicare patients exclusively to avoid this problem.

The interesting thing about First assisting is that as a physician you might be better off if you are not licensed. If you are an unlicensed physician then you will not come under the medical staff rules for physicians (ie BE/BC). On the other hand if you are not licensed then you are not eligible for Medicare. Kind of a catch 22. I would agree that someone might have a hard time getting on with a first assist company, but if you find a sympathetic surgeon they might be willing to train. Its much the same issue with privileges. It largely depends on how much the surgeon is willing to advocate and how much pull they have.

That is interesting. I suspect that it does have to do with the environment; one might have more luck in a practice owned surgery suite or outpatient center than a hospital.

 

[core0]

Perhaps that is true in some states.

But recently the surgical assist group I've been using has had to request information about insurance billing up front, because they have not been paid for several Medicare cases. They claim its because Medicare will not pay for CSAs, only PAs, RNFAs, and MDs/DOs. Just today, the guy who was sent over had to call a colleague to come and replace him when he found it was a Medicare case. I haven't investigated it further, just took their word for it. They recommended I use MDs for my Medicare patients exclusively to avoid this problem.

If they are getting Medicare to reimburse for RNFAs they are doing something wrong. They didn't reimburse in 1996 when I was an SA and they haven't changed that to my knowledge. Medicare essentially has three groups of people that they reimburse for E&M (including first assisting). Physicians (for everything), non-physician providers (at a percentage of the physician rate) and everyone else (for 99211). If I remember correctly NPPs have been reimbursed for first assisting since 1986.

The problem that you describe is very common. When I worked in the OR the hospital used to pay a token amount for Medicare cases (I think that it was $20 per hour). That was to keep the physicians happy so that they had an assist for the cases.

As for using MDs for the Medicare cases, I'm not going to tell you how to run a practice, but frankly I think that this is a crap statement. What they are saying is that dump the worst paying cases on the physicians and they will take the rest. Assuming that you have a reasonable payor mix, they are making good money off the rest of your cases. They can do a few for free to stay on that gravy train. This is how most of the ortho practices that don't have PAs do it. They should make more than enough money off the rest to justify this. Especially since they don't have to worry about self pay (no pay) cases that you get stuck with on General surgery or ortho trauma call. The other way to do it is to make it the hospitals problem. Many hospitals have their own SA/RNFAs or have contracts to provide the service. You give up a certain amount of professionalism here.

That is interesting. I suspect that it does have to do with the environment; one might have more luck in a practice owned surgery suite or outpatient center than a hospital.

Outpatient surgery centers that aren't owned by hospitals is pretty much anything goes. I know one surgeon that trained their front desk person to assist. In the hospital if you have a surgeon that brings in lots of bucks they generally get their way until liability > money they bring in.

David Carpenter, PA-C