Physician Licensure During Disasters: A National Survey of State Medical Boards

To the Editor: In August 2005, Hurricane Katrina caused a public health emergency by displacing more than 4400 physicians in the greater New Orleans area and leading to the closure of 13 of 16 hospitals in New Orleans.¹ Out-of-state physician volunteers, many without professional licensure in the state in which they were providing critical medical services, responded to this unprecedented collapse of health care infrastructure. In effect, they were practicing medicine without a license, potentially placing them at risk for civil and/or criminal penalties.² Louisiana Governor Kathleen Blanco, responding to the public health emergency in her state, issued an executive order 12 days after Hurricane Katrina that suspended regular licensing procedures. In addition to providing license reciprocity, this executive order recognized physicians as agents of the state of Louisiana for tort liability purposes.³ We sought to determine the policies of each state regarding physician licensure during disasters.

Following approval from the institutional review board at Kansas City University of Medicine and Biosciences, a questionnaire was submitted via facsimile to the director of the medical board for each state and the District of Columbia. The first question was, “Does your state allow for expedited licensure [accelerated licensing procedures] for volunteer physicians responding to a disaster in your state?” It was followed with, “If yes, please check that which is most applicable: (a) expedited licensing process [expedited internal process], (b) exemption [license reciprocity], or (c) other, please explain.” Citation of any applicable specific policy or statute was requested. When we sought clarification, we interviewed the state medical board director or designated representative by telephone. Data were collected from June 2007 to September 2007.

Of the states, 18 (35%) do not permit expedited physician licensure or exemption. Thirty-two states and the District of Columbia (65%) had statutes specifically granting licensure for volunteer physicians during a disaster; 13 of these 32 states offered licensure via expedited process while 19 states and the District of Columbia offered licensure through exemption (direct reciprocity) (Table). No states were classified as “other.”

Licensure is a central issue for volunteer physicians. Although physicians “federalized” during a disaster, such as those affiliated with the US Public Health Service or a disaster medical assistance team, do not require state licensure,⁵ private-sector physicians may volunteer without certainty of legal and professional standing. Current strategies available to states to address licensing and other issues during emergencies include the Uniform Emergency Volunteer Health Practitioners Act (UEVHPA),⁵ the Emergency Management Assistance Compact (EMAC),⁶ and the Emergency System for Advance Registration of Volunteer Health Professionals (ESAR-VHP).² The UEVHPA provides legislatures with a guide for licensing health care professionals during states of emergency. The EMAC, a nonfederal compact for mutual assistance between states, offers a comprehensive approach to interstate mutual aid but contains no provision for licensure of private-sector physicians. The ESAR-VHP is a national system of state-based emergency volunteer registries that verifies licensure and other base credentials but does not provide for license portability.

There are many important issues pertaining to physician response during disasters, including licensing, credentialing, liability, safety, and compensation. This study focused strictly on licensure of private-sector physicians during declared states of emergency. The finding that 18 states do not currently have policies allowing accelerated physician licensure indicates the potential for suboptimal medical care in the event of a large-scale disaster. Although the issuance of executive orders and “federalization” of physicians may be useful as reactive measures, a policy of accelerated licensure during states of emergency may enhance the rapidity and magnitude of physician response.

Author Contributions: Dr Boyajian-O’Neill had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Boyajian-O’Neill, Gronewold, Glaros, Elmore.

Acquisition of data: Boyajian-O’Neill, Gronewold.

Analysis and interpretation: Boyajian-O’Neill, Gronewold, Glaros.

Drafting of the manuscript: Boyajian-O’Neill, Gronewold, Glaros.

Critical revision of the manuscript for important intellectual content: Boyajian-O’Neill, Gronewold, Glaros, Elmore.

Statistical analysis: Glaros.

Administrative, technical, or material support: Boyajian-O’Neill, Gronewold, Glaros, Elmore.

Study supervision: Boyajian-O’Neill.