The cessation of reciprocity in licensing will take medicine back to the Middle Ages

LLike many other 3-year-old boys, Braxton Davis is lively and sometimes playfully mischievous. But he might not have reached that age if states hadn’t temporarily relaxed medical licensing requirements during the pandemic. And the path for many other children and adults with potentially life-threatening health conditions could become more difficult as the door closes on more flexible medical approvals.

Braxton’s parents, Beth and Brent, live in a remote area of ​​northern Georgia. Before Braxton was born, a routine fetal echocardiogram done near his home showed something was wrong with his heart. The problem was diagnosed as Tetralogy of Fallot, a congenital heart disease that is actually a combination of four heart defects that disrupt normal blood flow. Fixation of tetralogy of Fallot may require multiple surgeries after birth, but how many cannot be determined until the newborn is examined.

Braxton’s parents, already feeling the normal tremors associated with impending parenthood, began preparing for the unusual and unfamiliar obstacles they would face upon Braxton’s arrival.


When Braxton was born in January 2019, it became clear that the first surgery would have to be done sooner rather than later. When he was just three weeks old, while I was working at Vanderbilt University Medical Center in Nashville (a three-hour drive for Braxton’s family), I placed a shunt in his heart that helped blood flow from the left ventricle to the right ventricle. This operation is usually followed by another within four months. But Braxton’s case didn’t follow the usual trajectory: his left coronary artery crossed in front of his heart, and an incision would be required for that repair. So we decided to postpone his next surgery so his heart would get bigger and stronger and his chances of a successful surgery would improve.

The timing of Braxton’s second surgery has been turned upside down by the pandemic and complicated by my move from Vanderbilt Johns Hopkins Children’s Center in Baltimore, 10 hours and four states from Braxton’s home. However, his parents wanted to continue his care with my team, some of whom came with me from Vanderbilt because of our medical history and experience of Braxton’s complicated condition – a natural hope for any parent coping with so much complexity and stress.


In normal times, Braxton and his family would have come to Baltimore for several pre-surgery appointments, some as short as 30 minutes. Alternatively, I could have applied for and received a medical license in Georgia, an administrative process that can take up to eight weeks, even for experienced board-certified doctors. After the surgery, Braxton and his family would have to return to Hopkins for at least two post-operative check-ups.

But as the pandemic gathered momentum in the US, the licensing flexibilities afforded by both the federal and most state governments enabled the Braxton medical team, including myself and my colleagues in Baltimore, and his specialists in Georgia to be flexible and change quickly in how Braxton’s care was delivered. These changes allow medical professionals licensed in one state to treat patients in other states. This was a critical change for telemedicine because prior to the pandemic, physicians could only care for patients who were physically located in a state where the provider was licensed at the time of the visit.

My hospital and its healthcare system, like many others across the US, has been able to quickly and safely scale out telemedicine services to reach patients at home during the crisis and beyond.

This combination of licensing flexibility and telemedicine services gave physicians more flexibility to meet the needs of their patients no matter where they live. In fact, thanks to telemedicine, I wouldn’t mind if all my future surgical consultations were virtual. Online meetings allow parents, grandparents and other family members from across the country to process together what could be difficult news about a child’s upcoming surgery and what the future holds as many of my patients will need care for the rest of their lives .

Virtual pre-op appointments ensured Braxton’s second surgery, performed in July 2021, was not delayed. During this operation we successfully completed a full repair of his heart. After a week’s stay, he and his parents went home to Georgia and I followed him afterwards via telemedicine and checked the incision site on video. Braxton continued to see his local cardiologist.

However, in the summer of 2021, many states lifted licensing reciprocity, forcing providers to cancel thousands of telemedicine appointments with office-based patients living in states other than where the provider is licensed. These reintroduced restrictions are disrupting long-term care for patients, causing many to seek new doctors and then change — and delay — their care.

Although Braxton’s recent surgery was successful and there’s hope he’ll never need another, it’s still important that he has regular check-ups, many of which can be safely done via telemedicine. However, as state licensing rules are reinstated, Braxton’s access to medical care will be restricted.

The fact that different federal states have different admission rules makes sense for certain professions. For example, traffic laws in Georgia might be different than just across the border in South Carolina, so you probably don’t want a Charleston attorney representing you for a speeding ticket in Atlanta. But a boy’s heart – or any other part of the body – should always function the same, no matter what state the boy is living in. The patient’s clinical care does not change because he or she has crossed a line on a map.

I don’t understand why a respected doctor in Maryland with patients in different parts of the country would need to be licensed in all of these jurisdictions, a process that may take up valuable time that his patients may not have. If I can call a Georgia pharmacy to prescribe post-op medication for Braxton, why shouldn’t I be able to call him as his surgeon to come in after his surgery?

People like Braxton, who live in remote areas, sometimes have no choice but to seek medical care across state lines to treat rare and complicated conditions because there is no specialist where they live. This is especially true for children given the nationwide shortage of various types of pediatric specialists.

Government officials must permanently expand and simplify state licensing flexibilities temporarily granted in response to the Covid-19 pandemic. This move would allow patients to receive telemedicine services from their preferred providers wherever they are. Possible solutions such as Temporary Mutuality to Ensure Access to Treatment Act (TREAT).are a step in the right direction.

A return to the pre-pandemic days, when clinicians were limited to only attending to patients physically in their state of admission, would undo much of the progress that has been made to improve patient access to care to improve significantly. In other words, the next kid faced with Braxton’s medical diagnosis might not be so lucky.

Bret Mettler is Director of Pediatric Cardiac Surgery at Johns Hopkins Medicine. The views expressed here are his own.

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