From the time of evolution until the current modern age, through generations, the human being has struggled not only to preserve life but also conquer the horizons of skillful existence. Over his journey, every rational existence by nature has to contribute to its society, in one way or the other and over time has had lessons learned from his ancestors then contributed by passing it along the chain of humanity onto future generations.
He started the journey by means of simple hunting, farming, and crafting, propagating along with the learned unique skills through rudimentary mentorship.
Today, profession and skill have been shaped into a formal education entailing sophisticated but organized educational system. Majority of the time he incurred positive outcomes but in some instances have writhed significant setbacks. Human being by nature has an inherent tendency to be competitive and may even go further to please that instinct by shortcutting the corners within the journey of his professional try-So, social programs were introduced under the patronage of public safety and quality assurance. Hence, the notions of certification and licensing were introduced.
The former was to set up the validity of certain characteristics of an object, person, or organization qualification to govern whether a particular individual is knowledgeable enough in a given occupational discipline so to be classified as “competent to practice” in that scope. But, licensing or occupational accrediting also called professional licensure, is a form of government guidelines requiring a license to pursue a particular profession for “compensation”.
Occupations that can have a significant deleterious influence on individuals, like physicians and lawyers, need professional licenses in most developed countries, but ample jurisdiction also requires licenses for professions without any significant negative risks, like plumbers, taxi drivers, and electricians.
Licensing creates a regulatory barrier to entry into a selected group of professions, resulting in higher wages for those with licenses and higher costs for consumers.
What are societies and boards?
Board was formed to signify a group of people with necessary skills and knowledge about a profession assigned with the responsibility to govern a particular organization, company, societies or other entities to enforce the licensing requirements. Boards sustain their own statutory requirements. Hence, the sole role is to collectively enforce privileging policies.
History and evolution of license
The history of licensing reaches back to the 17th century. In contrary to what is commonly perceived, the Western countries have never operated as a purely economic system in which transactions between private parties are free from government intervention (laissez-faire capitalism) such as regulation, privileges, tariffs, and subsidies.
The Western monarchy monopolies, in particular, favored parties, say the colony at Virginia was founded by such a monopoly and reserved land and mineral rights for itself. Colonial and early state governments in America regulated property and the market. Licensing establishment has a historic succession. Middle age alliance classified access into distinct occupations.
The 13th and 14th centuries saw elementary forms of medical licensing in Germany, Naples, Sicily, and Spain. By the 20th century, there was an explosion in the number of occupations liable to a licensing requirement. Since 1950, the percentage of the domestic workforce in positions vulnerable to a licensing requirement has multiplied 500 percent and now stands at no less than 25 percent of the economy.
Occupational licensing is now one of the nation’s principal forms of economic regulations. Among the occupations subject to a licensing requirement are barbers, bartenders and cat groomers which have no or minimal risk to human lives.
By definition, certification is a formal process by which an authorized person or agency assesses and verifies and attests in writing thru issuance of a certificate the attributes, characteristics, quality, qualification or status of an individual’s professional services is in accordance with time-honored standards.
Licensing and certification today
The concept of licensing and certification has evolved from the fairness of creating some kind of quality professional standards for goods and services rendered by individuals or an entity to a more sophisticated procedure and protocols that in many aspects have had little to do with quality and more to do with control and power of sway.
It has not only extended to other careers which by nature do not necessarily present a direct danger to the society but also have widened the scope of its intervention with the inadequate reason for doing so by the board of directors. Even though, the overall intent is as attractive as values determined within the specific context of the professional interaction, however, the point of this argument is beyond rhetoric, which will be clearer as we expand our discussion later in this piece.
Only to keep in mind, today disciplinary actions against a licensee are by far harsher and thresholds at all time low, hence are important to contemplate that some professional achievements are the person’s lifetime investment, and its full-scale application is a big price paid for breaking bureaucratic dogmata.
The complex licensing system will invite bureaucracy, and some board decisions may deem accountability overkill and too costly in the individual’s life.
Public safety and licensing
Public safety is undoubtedly the most important reason to put in place a system that ensures its autonomy and quality assurances for every profession more so for those with direct responsibilities with human life. Even so, the necessity to put in place a micro-management structure which also encompasses actions that invade individual privacy and dictates favoritism is the substance of controversy.
The important is to support a reasonable balance and scope of administrative involvement, as excess intervention can have paradoxical sequels. For instance, today because of the recent government crackdown on the opioid crisis by lowering the threshold on license suspensions and revocations significant numbers of physicians feel reluctant to prescribe opioid analgesics to patients with chronic pain conditions.
Economy and licensing
Concept of licensing and certification, in general, is against what a free market exemplifies. In fact, it provides a tool for government agencies to alter the expansion course of a particular profession and service within a market or region. Thus, the fair is to postulate that economic implication of controlled supply of services and goods is anything, but a free market, as it would be destined to help those at the end of the monopoly hierarchy chain.
For example in 2017 an article published by the foundation for economic education highlights “Both, directly and indirectly, the American Medical Association (AMA) controls, the licensing of physicians, the accreditation of medical schools, admittance into medical schools, and the payment policies of insurance companies.”
Politics of licensing
For decades the Licensing and Certification policies have been primarily the topic of partisan debates. It has merely served as the subject of “devil’s advocacy” for the politicians desperate to gain the votes of certain professions, but ultimately, according to the Bureau of Labor Statistics, about half of U.S. workers hold an occupational license, a large increase from 5% in 1950.
Today following a report in the real clear politics, 2020 presidential candidates Joe Biden Echoes Libertarians’ Call on vocational Licensing by stating,
“You know if you are a hair braider, you braid people’s hair. You have to get a license to do something like 400 hours of training,” he said before pausing, admitting he should be “more careful” with his words, and concluding that licensing requirements were part of a greater unseen effort “not to help the worker.”
Government control over intellectual and the rich
Intellectual’s constituency within a society is the foundation of the economic prosperity and competitiveness of that establishment. As described twenty years ago by Dwight Macdonald in a series of published articles about Politics on the responsibility of peoples and, specifically, the responsibility of intellectuals. Virtually, I enjoy the notion! Historically the balance of democracy, individual liberty has suffered profoundly in the hands of political extremists.
In order for the governments to contain the power of intellectuals, they have developed an efficient procedure to harness and control its prodigy through accreditation and privileging by the hands of the group of individuals tied through political affiliations.
Occupational Licensing is in fact “the modern pseudo-monarchist aptitude” over its intellectual citizens; equally is a well-executed process that functions by redirecting the economic benefits and productivity driven by the great minds away from its cradle into the arms of selected persons, groups and entities.
Monopoly of licensing
Anyone who has lived through a less than an authentic free market must be familiar with the concept of kickback practices, monopoly, and favoritism. The world of licensing and certification, especially with regards to the profession of medicine has also its own historical flashbacks. Pursuing a medical career is one of the hardest and most expensive talents.
To earn the title of Medical Doctor is riddled with challenges, but continuing medical education sustains the noteworthy political conspiracy of its own. A medical license is extremely lucrative and like it, breakers into sub-specialties become more segregated. So much that in certain European countries the Licensing authority would issue a license to practice exclusively to a particular specialty. In other countries like the United States, the authorization to treat patients is deemed universal.
Either form of jurisdiction provides overwhelming authority to a certain group of people who may enforce a physician’s scope of practice based on a written protocol subject to bias and prejudice. For example, a medical board may recognize two physicians performing spine surgery, one with neurosurgery background and the other orthopedics.
Even though what matters is the individual physician’s level of skill and knowledge in spinal surgery, but then again historically it has not been approached as such. One of the turf battles of medical disciplines which involves licensing boards is about which profile of a physician group should be elected as exclusive specialists to perform spine surgery. Similarly, plastic surgeons support a similar position against other professions as the elite discipline to perform cosmetic surgery.
How does it translate in today’s scenario?
Today occupational license is more about state control than is public safety. Certification is about profiling that rests in the number of bureaucratic assumptions that only satisfies the regulatory protocols, which also subjects the licensee to focus exclusively on satisfying mandates contrary to delivering quality service.
How does it translate to medical practice?
Ensuring quality patient care and securing safer medical practice is a sine qua non to any society which can be achieved through appropriate modalities, but hardly through the transference of liabilities delivered by healthcare illiterates.
Medicine legal significance
The Legal ramifications are hypocritically influenced by the biased licensing practices, as it complicates the jurisdiction of the application of the skills particular to that dominion. With the advent of the telehealth system and travel medicine, multitudes of Grey zones have been created within the system that would indiscriminately place the practicing physician’s licenses at jeopardy. One such example is the propensity of licensing agency failures to recognize the validity of doctor-patient relationship for a first telehealth visit, or profiling it as practice without a license if the patient is outside the state jurisdiction during the remote virtual encounter.
The legitimacy of the licensing for the perseverance of public safety has become a tool for the abuse of power and invasion of professional endeavors as well as autonomy. The concept of standard of care is illustrative of grounds for such perversion.
The concept of Standard of care
Standard of care is legal terminology and the only degree of prudence and caution required of an individual who accepts the responsibility of caring for another person or entity. The requirements of the standard are closely dependent on individual circumstances.
Whether the standard of care has been breached is determined by a person, or group of persons such as an expert and licensing committee, or the court of law, which evaluates facts via a legal proceeding, usually a trial.
The standard of care in the medical profession is more complex as variables to every circumstance within which the medical service was delivered, such as economy, social attitudes, and technological development. Hence, across the board application of administrative jurisprudence on the standard of care demands significant burden on the physician by leaving the sum of shady unclear areas as in the eyes of the members of the licensing committee what pertains to standard.
The officialdom around licensing is one of the reasons why the better part of the physician community are dissatisfied, burned out and feel vulnerable.
Variability of Standard of care is an open-ended opportunity for the licensing agent and serves as a weapon of mass manipulation and control against medical professionals and other occupations.
Creating the monster
Knowledge, skills, and technology have made tremendous progress in the past century. Humankind has been able to win battles over diseases and hardships, yet has not been able to evenly distribute itself across socioeconomic and geographic boundaries.
There have been attempts towards redistributing wealth through social programs or revamping professions through bureaucratic licensing and certification initiatives throughout government support. But all have failed by forging a regulatory monster that has averted the attention of physicians (in this scenario) from one hundred percent patient-focused medical practice to overwhelmingly regulatory focused compliance obedience which has paradoxically affected the quality of care, if not physician burnout.
Let’s emphasize by repeating; public safety is by no means the substance of shortcut, but interference with professional judgment is counterproductive to the standard of care. In fact, a variety of alternatives are available that help administrations offer high-level oversight, promote safety without jeopardizing the quality of medical care and prevent interfering with the personalized clinical judgment.
In other words:
1. The system must support the locality of its jurisdiction to the smallest- the larger the community, tougher to keep bias and bureaucratic prejudice to the least, as even stiffer to show a standard of care.
2. Federal and state laws must make sure the sovereignty of the local codes and their transparency down the ladder of the hierarchical constitution.
3. Boards and groups must be dissolved, as grouping and profiling make the system susceptible to the practice of favoritism, monopoly, prejudice
4. Use independent peer reviewers within the communities to decide eligibility, ability and public safety.
5. Conceal the identity of the licensee to the reviewer to prevent bias
6. Conceal the title of specialty profile from the reviewer under which a licensee functions under.
7. Keep objectivity at skills learned and services delivered using particular skill sets
8. Conceal the identity of reviewers from one another in every case to achieve the most independent feedback.
9. Treat every case as insider information and make it private until the legitimacy of wrongdoing is confirmed by the independent reviewers.
10. Review qualified skills and services by proficient, And non-professional level services with non-professional
11. Figure the value of any service at the “level” of their discrete interaction or association
12. No need for licensing to make sure safety.
13. Create full transparency and apart from during the peer review
14. Accountability must be in reflection of the skills rendered.
15. Knowledge, skills, integrity, ethics, professionalism is not determined by the bureaucratic process, but within the context of the individual’s immediate environment.
16. Knowledge and skills never expire and are always useful, but can be wasted through wrong policies and unfair licensing regulations.
“Licensure is the government’s means of holding the power of veto and sways over the intellectual constituents, ascendancy granted to them by selected illiterates”
Knowledge and skills are the most powerful trait of every citizen. Having control over knowledge translates into dictating and harnessing the power of the intellectuals, contrary to the benefit of the public. On balance, Too much of a good deed cannot always be for the public interest and nor will respect individual self-determination.
Today’s licensing boards, prohibit individual autonomy, at times on pain of criminal liability from engaging in conduct that poses no threat of detriment to any person or to the community. Such a regime causes injury rather than protecting against it.