It is the year 1224 in the city of Sicily, and a young physician gathers his credentials to file for a medical license. He collects proof that he has studied for over eight years in physick, surgery and logic. He proudly adds a letter from his master physician mentor extolling his extraordinary skill in leech placement and uncanny facility in astrology. The young physician nervously heads off, credentials in hand, to be examined in public by a committee of master physicians. If he passes, the emperor himself will issue a medical license. If he fails, he will be jailed if he attempts to practice medicine again.
While many may think of it as a modern concept, credentialing has been a part of physicians' careers since long before the Middle Ages. For nearly as long as medicine has been practiced in society, some form of credentialing has played an important part in ensuring the physician is capable and qualified to perform his or her duties.
As far back as 1000 BC, the ancient Persian cult of Zoraster outlined the process for physician “licensure.” The Vendidad, a book of religious law, states that to earn the right to practice medicine a candidate had to prove himself by successfully treating three heretics. If all three lived, he was considered fit to practice medicine for “ever and ever.” If all three died, he was denied the right to practice medicine.
By the medieval period, the credentialing process was becoming more involved. In 13th century Paris, the formation of the College de Saint Come split the barber surgeons (surgeons of the long robe) from lay barbers (barbers of the short robe). To become a member of the College, and thus a surgeon of the long robe, one had to meet specific conditions for admission and pass an examination given by a panel of surgeons.
During this time period, similar changes were occurring in Sicily. King Roger II mandated in 1140 that anyone who had not passed an examination would be forbidden to practice medicine. His grandson, Frederick II, expanded this declaration in 1224 by setting up specific guidelines to obtain a medical license. A candidate was required to study logic for three years, study medicine and surgery for five years, and practice under an experienced physician for one year. A surgical candidate was required to study the art of surgery and anatomy for one year. After completing these requirements, a candidate had to be examined in public and approved by a group of master physicians. These requirements were so effective in reducing the number of sham physicians that similar laws were implemented in Spain and Germany.
By the 1500s, “licensure exams” seemed to be the norm in order to practice medicine. The English Act of 1511 was passed during the reign of Henry VIII, preventing anyone from practicing medicine within seven miles of the city of London without being first examined and approved by four expert physicians. Outside of London, physicians were required to be approved by similar bodies in their own diocese.
By the time Benjamin Franklin was forming the Philadelphia Hospital, the first hospital in America, it was still uncommon for practicing colonial physicians to have attended a formal medical school. Mr. Franklin required physicians to be at least 27 years old, have apprenticed within the city of Philadelphia, have studied physick and surgery for at least seven years, and pass an examination by six physicians of the hospital before being admitted to the housestaff. If a candidate was not a resident of Philadelphia, he was required to reside in the city for at least three years before being examined.
In modern times, physician credentialing has become increasingly complex with the advent of the information age. While such concepts as licensure exams and proof of training still play an important role, modern credentialing considers a wealth of additional information ranging from practice history to background checks. In 1990, the government-run National Practitioner Data Bank was launched to keep track of professional misconduct across all 50 states. Today, hundreds of for-profit companies have begun gathering and verifying information on physicians' credentials.
Yet even with the wealth of information available, we are occasionally reminded of the importance of accuracy. In one such case, Michael Swango, MD, was repeatedly hired and dismissed from residency programs across the country following questionable patient illnesses and deaths. After investigation, Dr. Swango, who had served time on a felony conviction for poisoning coworkers before entering his second residency program, was charged with nearly 30 deaths at hospitals in Ohio, South Dakota, New York and Africa from 1984 to 1996. He was found to have used altered documents to lie about the severity of his conviction and previous dismissals.
As we enter a new millennium, combining over 3,000 years of experience with modern technology, perhaps we will finally get the credentialing process right. But despite the sheepskin or implanted chip, we should remember that physicians must be judged by more than the letters after their names.