Due to the unintended consequences of a change in California state law effective in 2022, residents who completed a year or more of training after medical school – such as a transitional internship – were no longer considered eligible for a postgraduate training license, or PTL. Instead, they had to apply for unrestricted licenses with only a 90-day grace period, after which they would no longer be able to work until their unrestricted licenses were granted.

The usual wait for a California medical license is far beyond 90 days. This created a crisis in the making for Seth White, MD, an intern at Loma Linda University (LLU) Medical Center, and about 300 other residents across the state. Dr. White had completed a transitional year in Michigan after graduating medical school in 2021. Would they lose time in their training, or even lose their residency positions altogether if they couldn’t obtain licenses?

Dr. White advocated tenaciously at the highest state levels, with the support of his residency program director, Jason Gatling, MD, Program Director for the residency at the Department of Anesthesiology at LLU, to avert the crisis and enable the residents to keep on taking care of their patients. If you think advocacy is just tilting at windmills with little to show for the effort, think again! Here’s their remarkable story as told to their colleagues and ASA Monitor authors Nicholas Knowland, MD, and Justin Calvert, MD.

– Karen Sibert, MD, FASA

What is the normal process of applying for a license?

Dr. Gatling:

When applicants match to our residency program, which typically occurs during March of the fourth year of medical school, they are instructed on how to apply for their license. This process is started before the start of residency training as the application can take months to process.

In California, they apply for what is called a Postgraduate Training License (PTL), which is sponsored by the residency institution and awarded by the Medical Board of California (MBC). Following the completion of three years of residency training, the resident physician can then apply for an unrestricted California medical license.

Dr. White:

However, as of January 1, 2022, California Senate Bill (S.B.) 806 implemented a change. Any individual who had previously completed a year of ACGME training was no longer eligible to obtain a PTL and instead would need to apply directly for an unrestricted license. This new law allowed only a 90-day grace period, during which time these residents could practice while awaiting licensure.

Because of my out-of-state transitional year, I fell into this category. So did all residents who had completed a preliminary year out of state prior to coming to California to begin their advanced training programs. On July 1, we started residency, and our 90-day countdown began.

Dr. Gatling:

It is important to note that these residents were unable even to start the license application process until completion of their preliminary programs at the end of June. This situation was further complicated by backlogs at the MBC stemming from pandemic-related staffing shortages, as well as the expanding number of applications, which increased from 7,500 to more than 10,000 in the last year.

When did you recognize a potential issue with the process for your licensing process?

Dr. White:

I finalized my application submission on July 25. On August 18, I reached out to the MBC and was informed they normally allow 60 days from when they receive an application before they will provide an update. This meant my update would not come until September 23, extremely close to what I expected would be the end of my 90-day grace period, October 1.

Given the urgency, I again contacted the MBC. On September 13, they informed me that they were in the process of reviewing applications received up through July 4 and were 12 days behind their own expected timeline. At that point, I reached out to my local graduate medical education (GME) office to find out what would happen if I did not receive my license by the deadline.

The news was not good. I was told I would be placed on unpaid leave for a period of up to one month, at which point a formal “separation process” would occur and I could no longer be employed at Loma Linda. This would also put my residency position in jeopardy. It was then that I approached Dr. Gatling.

Dr. Gatling:

I was not aware of the issue until Seth brought it to my attention. Following our conversation, I began regular discussions with GME leadership to consider options. Would Seth only be held out of clinical work? Could he do research or be assigned other nonclinical duties? Could vacation time be used to extend the time before is formal separation?

Despite our efforts, the outlook was grim. I reassured Seth that, regardless of what happened, we would save his spot and find a way to get him trained, though that might mean delaying him another year.

With few options to work with, the GME staff and I began planning how we could support Seth and other residents like him if their employment were to be terminated. As a prime example, we set aside resources to cover their health insurance during this potential unemployed period.

What were your biggest concerns during this time period? Did you talk with other residents, and did you realize how widespread the issue really was?

Dr. White:

I was worried about the ultimate downstream effects. Though I was confident my spot in anesthesia was secure, the interim was still very uncertain. In speaking with other residents at our institution outside of the anesthesiology department, I learned they too had significant anxiety. Many other medical residents didn’t have the assurance that I had received from my department and were truly concerned about the effect losing their residency positions would ultimately mean for their careers.

Financial stress was also a huge factor. Any sort of delay is obviously lost future earnings. More immediately, my wife and I had just recently moved across the country, and the thought of unpaid leave followed by unemployment was extremely daunting.

Lastly, I really battled feelings of shame and guilt. I remember asking myself, “How am I supposed to tell my co-residents and attendings that I’m being pulled from service?” Beyond my work colleagues, my family and friends don’t understand the complexities of the licensing process. Would they see me as culpable of some wrongdoing that led to this?

Dr. Gatling:

This was not an isolated issue. When Seth came to me on September 13, there were nearly 40 unlicensed residents approaching the deadline at Loma Linda. Through discussion with GME offices across the state, we estimated there were around 300 residents who stood to lose their residency positions.

What next steps did you take after realizing your training was at risk due to a problem with licensing?

Dr. White:

I knew I couldn’t sit idly by; I needed to take some action. In my conversations with the GME office, I asked if they had been in contact with the MBC. I learned that they had spoken with “licensing staff” at the MBC for over six months, expressing their concerns over this 90-day deadline, but had gained no significant traction. While they did not discourage me from acting personally, they made it clear they had little expectation of success in the endeavor.

I began searching for someone to reach out to, knowing that I needed to light a flare to draw attention to what was happening. I even considered reaching out to my local congressman. Fortunately, through my research, I was able to get the contact information of Richard Thorp, MD, an alumnus of LLU and one of the eight physicians on the MBC. I apprised him of my situation and the implications for similar residents across the state.

He was unaware of the problem and contacted the president of the MBC that afternoon. Soon after, I was informed there would be a follow-up meeting with the chief of licensing for the MBC on September 19. Unfortunately, from that meeting I learned that, while the MBC has executive power to issue licenses or write “cease practice orders,” they have no power to extend the 90-day grace period defined by the legislature, and therefore could not resolve the issue themselves.

There were really two approaches to this: extend the deadline or expedite the approval of those applications that were still pending. Expediting approval became the initial focus, but my application was still awaiting approval as September drew to a close.

I was surprisingly calm as the deadline approached. My contacts on the MBC informed me that the California Medical Association (CMA) was working on obtaining an executive order from the governor’s office that would extend the deadline, and I was assured my application was being expedited.

It was therefore a complete shock when, on September 29, three days earlier than the expected deadline, I received an email from the LLU GME office stating that I must hand in my badge and pager and could not come back to work the next day. To make matters worse, my electronic health record credentials were immediately deactivated, so I was unable to complete my shift and was forced to hand off the rest of my duties to the other members of my team. Needless to say, I went home demoralized.

To keep my mind off my situation, I spent the rest of the evening working with my wife at a local soup kitchen for the unhoused. Later that evening, the surprises continued because there was yet another email from the GME. This one stating that the executive order had been signed and I was to return to service the following day.

Thankfully the situation was suddenly resolved, albeit temporarily. Your efforts reached the desk of the governor at nearly the eleventh hour?

Dr. White:

Yes. On September 29, Governor Newsom signed an executive order granting an extension of the grace period through November 30. This provided enough time for the MBC to work through the remaining applications.

As for me, on November 21, my license was issued, nearly four months after my application was submitted. It is a true relief to have it behind me so I can fully focus on residency once again.

Does this mean the licensing issue is now resolved for residents in California?

Dr. White:

While the crisis was averted for me and my co-residents, without a systems-level change, it is likely to happen again to a new cohort of residents next year. If we are to continue with the structure established by S.B. 806, a system must be set up to ensure that these applications are flagged and expedited during the 90-day period so future residents can serve their communities and health care institutions without interruption.

Dr. Gatling:

We owe a tremendous debt to the Medical Board, the governor, and the CMA for their decisive action, but it cannot stop here. They must continue to work together to find a definitive way to amend this licensing process. If not, this problem will repeat year after year. While the MBC is working on potential improvements such as increased funding for staff expansion to help manage the ever-increasing applications, permanent change to state law is likely necessary to ensure a long-term solution.

What is the most important takeaway from this challenge?

Dr. White:

This experience highlighted the dangers of working in silos and the importance of communication outside of our immediate spheres of influence. Policymakers, health care systems, the MBC, the resident physicians practicing in California, and their patients are all significant stakeholders when it comes to medical licensing, but the system is fractured, and issues are isolated. My co-residents and I experienced first-hand the unexpected and unnecessary consequences of failure to communicate among these groups.

Thankfully, we also witnessed how one individual’s determination, amplified by collaboration and advocacy, can have a tremendous impact. Our experience emphasizes why continued physician engagement with policy and lawmakers is so critical.

Dr. Gatling:

Looking back at this experience. it strikes me that Seth, a future anesthesiologist, was the catalyst for change. He showcased what it takes to be a great anesthesiologist: ingenuity, determination, and a willingness to advocate for others. His efforts didn’t just help 300 resident physicians, but will ripple outward to touch countless patients through them. I am very proud.