MEDICAL LICENSING LAWS: AN INTERNATIONAL COMPARISON

ABSTRACT

Medical licensing laws serve as gatekeepers for the healthcare profession, ensuring that only qualified and competent individuals practice medicine. This paper explores the medical licensing systems of Bhutan, the United States, and the United Kingdom, each reflecting the distinct healthcare priorities of their nations. Bhutan seamlessly blends modern medicine with its rich tradition of holistic healing, while the U.S. tailors its licensing approach to regional needs. The U.K., on the other hand, emphasizes a standardized and inclusive framework. Despite their differences, these systems share key principles, such as ongoing education, ethical integrity, and patient safety. This analysis contributes to the global conversation on establishing fair and effective medical licensing regulations.

KEYWORDS

Medical licensing laws, Bhutan, United Kingdom, United States, Continuing Medical Education, ethical standards, licensing frameworks.

INTRODUCTION

Medical licensing laws play a crucial role in upholding the quality and integrity of healthcare systems worldwide.^[1] They set the bar for professional standards, ensuring that doctors and medical practitioners are competent, ethical, and well-trained. While every country has its own approach to medical licensing, these regulations ultimately reflect a nation’s legal structure, cultural values, and healthcare priorities.^[2] Nevertheless, medical licensing laws differ greatly across jurisdictions which brings significant challenges in achieving a universally accepted standard of medical care.^[3]

This paper examines the existing medical licensing laws from an international perspective, comparing jurisdictions to find the differences and similarities in their approaches. It will analyze the systems in countries such as the United States, the United Kingdom, and Bhutan including technological advancements, and ethical considerations. These discussions will show how socio-economic factors and resource availability shape licensing standards in each of these countries. Ultimately, this paper aims to contribute to the global conversation on harmonizing medical licensing laws while addressing local healthcare needs.

DEFINITION

Medical licensing laws are legal frameworks that are established by governments or regulatory bodies of countries to authorize individuals to practice medicine.^[4] Under these laws, there are usually specific educational, ethical, and professional standards that the aspiring practitioners must meet.^[5] Countries establish legal frameworks for medical licensing as it ensures accountability and also serves as a mechanism to enforce disciplinary measures when standards are breached.^[6]

KEY CONCEPTS IN MEDICAL LICENSING LAWS: FOUNDATION OF REGULATORY FRAMEWORKS GOVERNING MEDICAL PRACTICE

Qualification Standards- Medical licensing laws establish specific educational and professional standards (and/benchmarks) that individuals must meet to practice medicine. For instance, this could include graduating from an accredited medical school, completing a residency, passing the United States Medical Licensing Examination (USMLE) and mental, moral, and physical fitness to safely practice medicine.^[7] In cases like that of the United Kingdom, practitioners must register with the General Medical Council (GMC).^[8] These requirements ensure that all licensed physicians working in healthcare possess the necessary knowledge and skills to provide safe patient care.
Regulatory Bodies- There are various regulatory bodies that oversee the enforcement of medical licensing laws. As mentioned above, in the United Kingdom, the General Medicine Council plays an important role in licensing, compliance, and professional conduct^[9], while in the United States of America, the state medical boards are responsible for the same.^[10] On a similar note, in Bhutan, the Medical and Health Council under the Royal Government of Bhutan is responsible for medical licensing. Nevertheless, since 2023, the authority who looks after the certifications is Bhutan Qualifications and Professionals Certification Authority under the Ministry of Education and Skills Development.^[11] These bodies are not only responsible for licensing and professional conduct but also look after revalidation processes and often can also impose sanctions on practitioners who violate standards.^[12] Additionally, medical licensing laws also include mechanisms for investigating complaints against practitioners.^[13] Ultimately, these laws provide ways to impose disciplinary measures on those who breach ethical or professional standards.^[14] These disciplinary measures could range from fines to suspension, and in extreme cases, revocation of their licenses.^[15] Having such a system in place helps in maintaining the public trust in healthcare professionals.
Scope of Practice- Medical licensing laws define the scope of practice for healthcare professionals. They specify what medical activities practitioners are authorized to perform and not^[16]. Moreover, for harder and more specialized fields like surgery or anesthesiology, additional certifications may be necessary to ensure that the health practitioners are trained and qualified.
International and Cross-Border Licensing- As globalization affects healthcare delivery, international and cross-border licensing agreements are also becoming increasingly rampant.^[17] In the United States, for instance, the Interstate Medical Licensure Compact (IMLC) helps in facilitating easier licensure across member states, that addresses the workforce shortages while ensuring consistent standards of practice.^[18] These international agreements help in ensuring the enhancement of mobility for healthcare providers and improve access to care in backward areas too.

To sum up, medical licensing laws are fundamental to maintaining the integrity, safety, and quality of the healthcare systems worldwide. By ensuring these qualifications standards, and ensuring rigorous monitoring through regulatory bodies, they help in safeguarding public health while fostering trust.

MEDICAL LICENSING LAWS IN DIFFERENT JURISDICTIONS

Medical Licensing Laws in Bhutan

In Bhutan, the medical licensing framework is governed primarily by the Bhutan Medical and Health Council which was established under the Bhutan Medical and Health Council Act, 2002.^[19] They oversee the registration and licensing of medical professionals and ensure that they have the necessary qualifications to practice safely and effectively.

Registration and Renewal

Section 13 of the Medical and Health Council Regulations of 2005^[20], stipulates the criteria’s which must be fulfilled by medical professionals to be registered with the Bhutan Medical and Health Council (BMHC). The registration process involves submitting proof of recognized qualifications, completion of practical training, and other documents like character and medical fitness certificates. In addition to that, Section 13.4 states that “all foreign medical and health professionals including volunteers practicing in Bhutan shall be registered as temporary professionals being liable to the same disciplinary procedures under the regulations, as other professionals”.^[21]

As stated in Section 16.1 of the Regulations, “every certificate of registration shall be renewed every five years after initial registration for continued practice”.^[22] However, an additional criterion to be considered is that the practitioners must demonstrate participation in at least 30 hours of Continuing Medical Education (CME) within the past five years.^[23] This ensures that the medical professionals are updated with the ever-growing advancements in medical science and practice.

Ethical and Professional Standards.

Bhutan’s regulations also emphasize ethics, etiquette, and professional conduct. Section 4 of the Regulations sets out a detailed Code of Ethics that medical professionals must adhere to. This section sets out the duties to patients, society, and the profession. The key principles outlined in the Section for medical professionals includes obtaining informed consent, maintaining confidentiality, and ensuring non-discriminatory treatment. Moreover, it also outlines the specific ethical obligations like reporting communicable diseases to protect public health. If any of these codes are breached, then it can lead to disciplinary action outlined in Sections 6 and 18, which can range from suspension to permanent removal from the register.

Some of the key provisions of Section 4 are:

Patient Centered Care: Under the regulations, medical professionals must prioritize the care of patients above all else.^[24] They have the ethical obligation to act in the patient’s best interests and ensure respect and dignity.^[25]
Informed Consent: Medical Practitioners are also required to provide patients with clear information to facilitate informed decision making.^[26] This includes explaining the treatment options and the risks (and/or) benefits in a manner that patients can understand^[27].
Confidentiality: They also have the important obligation of maintaining confidentiality about patient information.^[28] Exception to this rule is only made when the disclosure of information is necessary to protect public health or to fulfill legal requirements.^[29]
Competence and Honesty: Professionals are required to keep their knowledge and skills up to date, and act honestly and transparently in all professional interactions.^[30]
Non-Discrimination: The Regulations also prohibits discrimination based on social, economic, religious status^[31] ensuring equitable access to healthcare for all.

Unique Features of Bhutan’s Medical Licensing.

One of the most unique features of Bhutan is the integration of traditional medicine (also known as gSo-ba Rigpa).^[32] Traditional medicines are the “indigenous medicine recognized as a full-fledged branch of medical science by the Act.”^[33] The Regulations recognize traditional medicine as a legitimate branch of medical science, and practitioners of traditional medicines must also be registered with the Bhutan Medical Health Council. Bhutan’s dual system approach to medicine shows its cultural priorities.

Bhutan’s medical licensing framework balances both modern medical practices and traditional practices. The inclusion of CMR requirements also demonstrates a commitment to keeping medical practitioners updated with advancements in the field while the emphasis on the ethical obligations that they have fosters trust and accountability.

MEDICAL LICENSING LAWS IN THE UNITED STATES

The journey of medical licensing in the United States has been one of transformation, from the loosely regulated practices of the 19th century to today’s stringent and structured system.^[34] Over time, organizations like the American Medical Association (AMA) and state legislatures have played a key role in establishing national standards, ensuring that physicians meet rigorous educational and ethical benchmarks before treating patients.^[35]

The late 19th century is marked as the turning point for the American healthcare system with the establishment of state medical boards and the adoption of licensure requirements.^[36] For example, the Illinois Medical Practice Act of 1877 introduced mandatory licensing exams and also established the Illinois State Board of Health to oversee medical practice standards.^[37] By the early 20th century, most states required medical practitioners to possess a diploma from an accredited institution and to pass a licensing examination.

Medical licensing is primarily governed by the individual state medical boards. Each state has its own medical practice act. Nevertheless, the Federation of State Medical Boards represent these boards and provide a framework for licensing and regulation across different jurisdictions.^[38]

LICENSING REQUIREMENTS IN THE UNITED STATES

To practice medicine in the United States, the practitioners must fulfill the following requirements:

United States Medical Licensing Examination (USMLE): Physicians must pass this three-step examination to show their medical knowledge, clinical skills, and decision-making capabilities.^[39] Practitioners who are foreign trained must also pass the USMLE and complete a U.S. based residency program.
Residency Training: Most states in the U.S. require the practitioners to complete an accredited residency program to gain practical, supervised experience in patient care.^[40]
Continuing Medical Education: License renewal is contingent upon completing a specified number of CME hours. For instance, California requires 50 CME hours every two years to ensure that physicians stay abreast of medical advancements.^[41]

ETHICAL AND PROFESSIONAL STANDARDS

State medical boards enforce ethical guidelines to maintain professional integrity and protect public health. Some of the key principles or standards are:

Patient welfare and rights: The practitioners must provide patients with sufficient information to make informed decisions about their care, respect dignity and uphold their right to privacy.^[42]
Confidentiality: Maintaining confidentiality is a cornerstone of medical ethics, with exceptions permitted only for legal or public health reasons.^[43]
Professional competence: Doctors must maintain and enhance their medical knowledge and skills through continuous learning.^[44]
Social responsibility: Professionals are encouraged to contribute to the betterment of public health, and support social policies that improve community well-being.^[45]

In conclusion, the medical licensing laws in the United States deliver high quality healthcare but ensure public safety and professional integrity. The historical evolution of medical licensing to what it is right now shows the nation’s commitment to advancing healthcare while adapting to challenges.

MEDICAL LICENSING LAWS IN THE UNITED KINGDOM

In the United Kingdom, medical licensing is primarily governed by the General Medical Council which ensures that doctors meet high standards of education, training, and conduct. To practice medicine legally in the United Kingdom, all physicians must be registered with the GMC and hold a license to practice. This license permits them to perform specific medical activities, such as prescribing medicines and signing medical certificates.^[46]

The GMC offers various types of registration for the medical professionals:

Provisional registration: For newly qualified doctors who have completed their medical degree and are undergoing a foundation year of training.^[47]
Full registration: Required for doctors who have completed their foundation training and are eligible to work unsupervised.^[48]
Specialist registration: Necessary for doctors wishing to work as consultants in a specific field.^[49]
General Practitioner Registration: Required for those intending to practice as general practitioners.^[50]

Registration Process:

Eligibility: First, to be eligible for GMC registration, applicants must hold a primary medical qualification from a recognized medical school. This qualification must be verified through the Educational Commission for Foreign Medical Graduates (ECFMG) and the Electronic Portfolio of International Credentials (EPIC).^[51]
Medical Licensing Assessment (MLA): From 2024, all overseas doctors must pass the MLA to join the medical register and this assessment will ensure that all new doctors meet a consistent threshold for safe practice before they are licensed to work in the United Kingdom.^[52]
English Language Proficiency: The applicants must also provide evidence of their English language proficiency. This is to ensure that doctors can effectively communicate with their patients.
Evidence of Fitness to practice: They must also be assessed on the applicant’s fitness to practice based on their postgraduate medical experience and may require references of good standing from previous medical regulatory authorities.^[53]
Documents: Applicants must submit the following documents:

Proof of primary medical qualification.
Evidence of English proficiency.
Internship completion certificate.^[54]

Account: They must also make a GMC Online account and complete the application form. Once the application is approved, they can work in the United Kingdom.^[55]

Ethical and Professional Standards

Good medical practice: The GMC’s guidance document “Good Medical Practice” sets the core principles that all doctors must follow.^[56] Doctors are expected to treat patients with respect and dignity.^[57]
Informed consent: Practitioners must ensure that their patients are fully informed before undergoing any treatment or procedure.^[58]
Confidentiality: They must maintain patient confidentiality and protect personal information. ^[59]
Continuous Professional Development: Doctors are required to engage in ongoing education and training to maintain competence throughout their careers and revalidation occurs every five years.^[60]

Medical licensing laws in the United Kingdom show a well-structured framework upholding the highest standards of medical practice.

CONCLUSION

Medical licensing laws are the backbone of safe and effective healthcare systems worldwide. This paper examined the frameworks in Bhutan, the U.S., and the U.K., each with its own approach. Bhutan uniquely integrates traditional medicine into its system, reflecting its cultural values. The U.S. operates a highly regulated but regionally flexible model, while the U.K. prioritizes uniformity and accessibility. Despite their differences, all three models share common goals, ensuring professional competency, enforcing ethical standards, and prioritizing patient well-being. These findings highlight the importance of balancing national priorities with global medical standards to create equitable and effective licensing systems.

REFERENCES

U.S. Medical Regulatory Trends and Actions, Guide to Medical Regulation in the United States, How Physicians Gain Licenses to Practice Medicine, Federation of State Medical Boards, https://www.fsmb.org/u.s.-medical-regulatory-trends-and-actions/guide-to-medical-regulation-in-the-united-states/about-physician-licensure/
Lyndsay T Glass, et al., Cross-border healthcare: A review and applicability to North America during COVID-19, Health Policy Open, January 10, 2022, Accessed through National Library of Medicine, National Centre for Biotechnology Information, https://pmc.ncbi.nlm.nih.gov/articles/PMC8744400/
Jacqueline Landess, State Medical Boards, Licensure, and Discipline in the United States, Focus (Am Psychiatr Publ), November 6, 2019, 17 (4), 337-342 Accessed through National Library of Medicine, National Center for Biotechnology Information.

^[1] Margaret E. Kruk, et al., High-Quality Health Systems in the Sustainable Development Goals era: Time for a Revolution, Lancet Global Health, September 5, 2018, Accessed through National Library of Medicine, National Centre for Biotechnology Information, https://pmc.ncbi.nlm.nih.gov/articles/PMC7734391/ (last visited on January 5, 2025).

^[2] Han de Vries, et al., International Comparison of Ten Medical Regulatory Systems, Accessed through RAND Europe, February 2009, https://www.gmc-uk.org/-/media/gmc-site/about/internationalcomparisonoftenmedicalregulatorysystemsfinalreportpdf25404378.pdf (last visited on January 5, 2025).

^[3] Carrie H. K. Yam, Medical Regulation: Ten Key Trends Emerging from an International Review, Accessed through Journal of Medical Regulation, Federation of State Medical Boards, 2016, 102 (1), 16-27, https://meridian.allenpress.com/jmr/article/102/1/16/80745/Medical-RegulationTen-Key-Trends-Emerging-from-an (last visited on January 5, 2025).

^[4] Eszter Kovacs, et al., Licensing Procedures and Registration of Medical Doctors in the European Union, Clin med (London), June 3 2014, Accessed through National Library of Medicine, National Centre for Biotechnology Information, https://pmc.ncbi.nlm.nih.gov/articles/PMC4952532/ (last visited on January 5, 2025).

^[5] Id.

^[6] Lawrence O. Gostin, et al., The Legal Determinants of Health: harnessing the Power of Law for Global Health and Sustainable Development, April 30, 2019, Accessed through National Library of Medicine, National Center of Biotechnology Information, https://pmc.ncbi.nlm.nih.gov/articles/PMC7159296/ (last visited on January 5, 2025).

^[7] U.S. Medical Regulatory Trends and Actions, Guide to Medical Regulation in the United States, How Physicians Gain Licenses to Practice Medicine, Federation of State Medical Boards, https://www.fsmb.org/u.s.-medical-regulatory-trends-and-actions/guide-to-medical-regulation-in-the-united-states/about-physician-licensure/ (last visited on January 5, 2025).

^[8] General Medical Council (GMC), Professional Standards Authority for Health and Social Care, https://www.professionalstandards.org.uk/what-we-do/our-work-with-regulators/find-a-regulator/general-medical-council (last visited on January 5, 2025).

^[9] Id.

^[10] U.S. Medical Regulatory Trends and Actions, Guide to Medical Regulation in the United States, How Physicians Gain Licenses to Practice Medicine, Federation of State Medical Boards, https://www.fsmb.org/u.s.-medical-regulatory-trends-and-actions/guide-to-medical-regulation-in-the-united-states/about-physician-licensure/ (last visited on January 5, 2025).

^[11] Bhutan Qualifications and Professional Certification Authority, https://www.bmhc.gov.bt/ (last visited on January 5, 2025).

^[12] Rajat Bhatnagar, The Complete Guide to the Medical Licensing Process for Physicians, Neolytix, https://neolytix.com/medical-licensing-process/ (last visited on January 5, 2025).

^[13] Drew Carlson and James N. Thompson, MD, The Role of State Medical Boards, 2005, 7 (4), 311-314, Accessed through AMA Journal of Ethics, https://journalofethics.ama-assn.org/article/role-state-medical-boards/2005-04 (January 5, 2025).

^[14] Tristan Mclntosh, et al., What Can State Medical Boards Do to Effectively Address Serious Ethical Violations? 2023, 51 (4), J Law Med Ethics, Accessed through National Library of Medicine, National Center for Biotechnology Information, https://pmc.ncbi.nlm.nih.gov/articles/PMC10937163/ (January 5, 2025).

^[15] Id.

^[16] Varun Krishnamurthy, What is Medical Licensing? Everything You Need to Know, December 13, 2024, Assured, https://www.withassured.com/blog/what-is-medical-licensing (last visited on January 6, 2025).

^[17] Lyndsay T Glass, et al., Cross-border healthcare: A review and applicability to North America during COVID-19, Health Policy Open, January 10, 2022, Accessed through National Library of Medicine, National Centre for Biotechnology Information, https://pmc.ncbi.nlm.nih.gov/articles/PMC8744400/ (last visited on January 6, 2025).

^[18] Interstate Medical Licensure Compact, Information for States, https://imlcc.com/information-for-states/ (last visited on January 6, 2025).

^[19] Bhutan Medical and Health Council, Dzi Seldra, https://dziseldra.com/company/bhutan-medical–health-council# (last visited on January 6, 2025).

^[20] Hereinafter “Regulations”.

^[21] Medical and Health Council Regulations, §13.4.

^[22] Id at §16.1.

^[23] Id at § 16.2.

^[24] Id at §4.2.1.

^[25] Id at §4.2.2-4.2.4.

^[26] Id at §4.2.5.

^[27] Id at §4.3.14.

^[28] Id at §4.2.10.

^[29] Id at §4.4.

^[30] Id at §4.2.7-4.2.9.

^[31] Id at §4.3.11.

^[32] Medical and Health Council Regulations, Definitions, § 3.3.33.

^[33] Id at § 3.2.21.

^[34] Jacqueline Landess, State Medical Boards, Licensure, and Discipline in the United States, Focus (Am Psychiatr Publ), November 6, 2019, 17 (4), 337-342 Accessed through National Library of Medicine, National Center for Biotechnology Information, https://pmc.ncbi.nlm.nih.gov/articles/PMC7011294/ (last visited on January 6, 2025).

^[35] Supra note 13.

^[36] Ronald Hamowy, The Early Development of Medical Licensing Laws in the United States, 1875-1900, Sixth Annual Libertarian Scholars Conference, Princeton University, October 1978, Accessed through Mises Institute (last visited on January 6, 2025).

^[37] Clinton Sandvick, Enforcing Medical Licensing in Illinois: 1877-1890, Yale J Biol Med, June 2009, Accessed through National Library of Medicine, National Center for Biotechnology Information, https://pmc.ncbi.nlm.nih.gov/articles/PMC2701151/ (last visited on January 6, 2025).

^[38] Jacqueline Landess, State Medical Boards, Licensure, and Discipline in the United States, Focus (Am Psychiatr Publ), November 6, 2019, 17 (4), 337-342 Accessed through National Library of Medicine, National Center for Biotechnology Information, https://pmc.ncbi.nlm.nih.gov/articles/PMC7011294/ (last visited on January 6, 2025).

^[39] The United States Medical Licensing Examination (USMLE), February 15, 2024, https://www.amboss.com/us/knowledge/the-united-states-medical-licensing-examination-usmle/ (last visited on January 6, 2025).

^[40] State Specific Requirements for Initial Medical Licensure, Federation of State Medical Boards, https://www.fsmb.org/step-3/state-licensure/ (last visited on January 6, 2025).

^[41] Physicians and Surgeons, Medical Board of California, https://www.mbc.ca.gov/Licensing/Physicians-and-Surgeons/Apply/Physicians-and-Surgeons-License/Examinations.aspx (last visited on January 6, 2025).

^[42] Frank A. Riddick Jr., Spring 2003, The Code of Medical Ethics of the American Medical Association, The Ochsner Journal, Accessed through the National Library of Medicine, National Center for Biotechnology Information, https://pmc.ncbi.nlm.nih.gov/articles/PMC3399321/#:~:text=The%20medical%20professional%20should%20safeguard,accept%20its%20self%2Dimposed%20disciplines. (last visited on January 6, 2025).

^[43] Id.

^[44] Id.

^[45] Id.

^[46] Medical Licensing Assessment, Medical Schools Council, https://www.medschools.ac.uk/medical-licensing-assessment (last visited on January 7, 2025).

^[47] Types of GMC Registration, November 8, 2023, IMG Connect, https://www.imgconnect.co.uk/news/2024/06/types-of-gmc-registration/390 (last visited on January 7, 2025).

^[48] Id.

^[49] Id.

^[50] Id.

^[51] Daniel Platts, How to Apply for UK GMC Registration, BDI, October 6, 2023, Accessed through https://www.bdiresourcing.com/img-media-hub/blog/how-to-apply-for-uk-gmc-registration/ (last visited on January 7, 2025).

^[52] Id.

^[53] Id.

^[54] Id.

^[55] Id.

^[56] Medical Students and the GMC, BMA, June 28, 2024, https://www.bma.org.uk/advice-and-support/ethics/medical-students/ethics-toolkit-for-medical-students/medical-students-and-the-gmc (last visited on January 7, 2025).

^[57] Id.

^[58] Core Ethics Guidance, BMA Medical Ethics and Human Rights, January 2024.

^[59] The Professional Standards, General Medical Council, https://www.gmc-uk.org/professional-standards/the-professional-standards#good-medical-practice (last visited on January 7, 2025).

^[60] Id.

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