In 2008, after a long and successful career of some 28 years, I decided to branch out and start a new business. It happened to be the delivery of telemedicine to non-urban communities, and after some two years, the company had gained substantial traction and I was making a respectable income. All the while, I had not had occasion to practice clinically, so I began considering the idea of simply retiring my license and leaving clinical medicine for good. After all, the requirements of maintaining a license to practice medicine were substantial. These included recertifying in my specialty, annual license fees, maintaining my DEA license, and most of all, the requirement for continuing medical education, which over each two to three year period were significant. So at the time I did it; I pulled the trigger and mailed the Missouri Board of Healing Arts my written request to retire my license—permanently. They quickly obliged and within approximately two weeks the sent me confirmation that my license was officially “retired”
And then it happened. Life began to hurl things at my wife and I that most people believe will never happen to them. To begin with, I had no sooner received the confirmation of my retired license than the stock market began what ultimately turned out to be complete collapse, all in mid-2008. Within nine months, my respectable nest egg had dwindled in value by every bit of 40% of its original value in January of that same year. We attempted to stop the financial hemorrhage from the blow that the markets had delivered, but to little avail. Despite frugal living and reinvesting our remaining savings in accounts receiving no more than 1-2% interest, we were not able to make up even a small fraction of our market losses.
But my wife was incredibly supportive and encouraged me to do the obvious and continue to pour my efforts into the new business I had started in a non-clinical setting where the income did not flow so easily. But nevertheless, with some hard work and patience, we began to realize some substantial fruits from our labor. In its second year, projections for the telemedicine reached well into six figures and gave us substantial hope that our ship was finding a stable course and that we would recoup our losses. But then, the unthinkable happened and we lost essentially all that we had invested in the company as well as the entire monthly income that we were beginning to count on once again. The story is rather a long one, but suffice to say that the other two partners had gone in a direction of which I was totally unaware. The financial impact of this event was completely devastating, both financially and emotionally. In our wildest dreams, we never imagined that in eighteen months we would lose eighty percent of our life’s savings though the stock market and a business deal gone very seriously wrong. We truly were completely devastated, without any real idea of how to proceed, just to meet our basic needs. And for the purpose of orientation, this now brings us to approximately May of 2010.
Between that time and now, we were required to spend down our life’s savings to a level that barely remained in the six figures. But do the math yourself; six figures to run a family and household will not stretch forever, and in April of 2012, I decided I had to return to my clinical practice in order to survive. I was fortunate because I had kept up all of my required CME and had been working in the (non-clinical) healthcare sector up to that time. So aside from some modest clinical “rust”, I felt that I still had a strong medical resume and began completing an entire application for a new medical license in Missouri. The Board itself, behaved admirably in supporting my application for re-licensure; that was not the problem. At that time, it was my understanding that the requirement to obtain my medical license essentially consisted of completing all the required CME for 2008-2011 (which I had already done previously), and possibly a letter of support from my personal physician. But it was, to say the absolute least, far more complicated than I could have ever imagined. For in the immediate several months before I began applying, there was a new regulation on the books in Missouri that required further in-depth assessment of my current medical expertise. Certainly one cannot argue with the need for caution when a physician has been away for more than two years, as medical knowledge changes rapidly and minds forget information with time. So no problem there.
The real difficulties began when I discovered the exact nature of the new requirements for relicensure. Initially, I read the regulation to mean that either I take and complete a single rigorous written exam (called the SPEX exam), or I needed to go to either Denver or San Diego for an extended battery of tests to assess my competency. Again, it all sounded difficult but logical enough, considering the Board is charged with protecting the public from incompetency. So after consulting with an attorney, I very quickly discovered that the Board far prefers the in-depth 7 day assessment at PACE (i.e. Physicians Assessment and Clinical Education). Upon checking into the details of PACE (and it’s Denver twin, the PEP program), I discovered the cost was high—very high. The first two days of written examinations (at PACE in San Diego) cost $9,500 (plus travel), and the five full day 2nd phase (five months later) cost another $4,500 (plus travel). This brought the total expense to slightly over $15,500. And even tough my wife and I are credit averse, we had few options at this point, so all $16,000 went onto a high interest credit card; but the Board left few (if any) options, so I did it. And perhaps you missed the timing, but from the time I first requested to sit for the exam (and had paid for it), until I received my final report, a period of nine months had passed, despite my constant request to “expedite” my testing.
And I should mention just a few words about the PACE testing. The first two days consisted of eight hours each of written and oral examinations that included Step 3 of the NBME testing, an extended medico-legal exam and a carefully monitored physical exam on a live patient while you were videotaped (there was additional written testing in my specialty). When I returned the second week, I spent each " day with a different examiner with whom I saw patients and was tested on my knowledge of each case for a total of 90 cases in five full days. Also, I had to complete an extended evidence based medicine project that was carefully evaluated. But while exhausting and stressful, it was all conducted very fairly by a highly professional group of examiners.
The wonderful news is that I not only passed this grueling 2-phase, seven day exam, but I finished with the score of “Level I”, which meant that I was determined to be “fully able to practice with no suggested restrictions”. I was ecstatic! I would finally able to obtain my medical license, and I did. But again, all told, from beginning to end, a total of nine full months were required to accomplish the testing. The wait seemed interminable with the PACE group at UCSD, and there was no hope of expediting any of the process. I was told it was, “very difficult to get all the parts of the testing coordinated amongst the faculty”. While the waiting was a nightmare, I will say on behalf of the PACE group that they were extremely professional to deal with, both during the testing and during the period I awaited my full 17 page report that they prepared. The report was thorough and exhaustive, but I felt that they were extremely fair in their assessment(s).
Conclusion In the weeks that followed, there has been a flurry of activity on my end, but you can imagine the likely events that have played out. To begin with, there was the four-week wait between finishing the testing and the Board receiving the report. Then there was an additional wait (about 3-4 weeks) while the Board reviewed and acted on my application request; all told requiring an additional two months from the time that the testing had been completed. And then there was the matter of the usual certifications that were required, including the request for the Missouri BNDD number and thereafter for the Federal DEA license. Surprisingly, these latter two “only” required about a month, but when you have waited so long already, it seems to move at a painfully slow rate. And although they are not issues that required licenses, almost every employer requires BLS, ACLS and PALS for my type of practice. This took another several weeks to even become a valid candidate for hospital credentialing, as all these merit badges were required. And finally, I am currently in the middle of the credentialing process, which itself could take another four to eight weeks.
So in closing, I would like to complete one math problem for you and total up the entire time required to re-apply for my Missouri license. The total interval from initial application until completing the process and receiving my license was from April 3, 2012 until late July, 2013. This represented a grueling process that required a full seventeen months to complete—a period of nearly 1" years (at a cost of $16,000)! And secondly, I would like to make a final recommendation for your consideration if you are currently considering the act of “retiring your license”. This recommendation would simply be that you move slowly and thoroughly consider my experience before you ever entirely give your license back to the State of Missouri. That is, fully comply with every letter of the law in maintaining your license, but if possible, maintain the option of either deactivating (i.e. rendering “inactive”) your license or better yet, of maintaining it for several months (or better yet, years) while you test your present situation against possible unforeseen events in your future. I know now that I surely wish I had done so! year. We attempted to stop the financial hemorrhage from the blow that the markets had delivered, but to little avail. Despite frugal living and reinvesting our remaining savings in accounts receiving no more than 1-2% interest, we were not able to make up even a small fraction of our market losses.