We began a conversation the other day about licensure being a grift. There is a difference between licensure and certification.

A license is a permit, issued by the government, that allows a person to carry out a certain activity. In order for licensure to exist, the government must first make it illegal to perform the activity, then issue licenses that permit those possessing those licenses to perform the activity.

Certification is where an entity certifies that a person meets certain standards. The entity issuing the certification can be a private business or a government. The value of the certification lies with the reputation of the entity that issues it. A certification can be issued without license- for example, UL laboratories. The government even issues licenseless certification- high school diplomas.

The issuance of a license can involve certification by the same agency that issues it- an example of this is a driver’s license. The DMV both ensures that the applicant for the license meets certain criteria and issues the license.

Alternatively, a government may require that another, outside entity certify that the applicant meets licensing criteria prior to issuing the license. Examples of this include lawyers and nurses. Passing the Bar exam or the NCLEX is a precursor to receiving a license to practice those professions.

A license can be issued without certification at all. Fishing licenses, for example. No one cares if you know how to fish- FWC just wants your license fees.

The only real reason for licensure is so that the state can control who can and cannot perform certain activities. The state always uses safety and quality control as the reason for requiring licenses, but this is the government we are talking about here. This means that politics eventually carry more weight than competence or safety.

This becomes a problem when the certification required to obtain a license is different for one group than it is for another. Say an American doctor or nurse has to pass certain hurdles while foreign doctors and nurses have different, lower standards. The oft quoted problem of a barber requiring more hours of training than a paramedic in Florida. (it’s true- Florida requires 1,200 hours of training in order to take the exam to be a licensed barber, but 1,112 hours of training and clinical time to be a licensed Paramedic)

Nursing is a great example of colleges grifting the system. In order to sit for the registered nursing exam, you must have at least a 2 year degree. That means 72 credit hours, but 30 of those 72 hours (42%) are courses like US History, English Composition, and Humanities that have absolutely nothing to do with nursing.

The reason that this happens is the people who are already practicing in that field want to make sure that there is a restricted supply of their skillset, so that pay remains high, or in some cases it is because colleges want to make lots of money. This is why Physician assistant programs also lobby so hard to have the degree requirements increased. There are a few colleges that teach PA as a 2 year associates degree, a couple that make it a 4 years Bachelor’s degree, while most schools make it a Master’s degree. In each of the preceeding cases, the PA applicant is still eligible to sit for the licensing exam. Making it a more rigorous educational requirements doesn’t make for better PA’s, but it does make for fewer PA’s, meaning that PA’s make more money.

So yes, licensing is nearly always a grift. In fact, I can’t think of a single time when it isn’t.

Categories: economicsGovernment


BobF · January 5, 2023 at 6:05 am

Would appreciate a PA versus Nurse Practitioner post whenever you get a chance. I was attended by one of the first PAs when the Air Force adopted the system long ago and one of my caretakers now is a Nurse Practitioner. I’ve read some of the requirements of each and find it interesting, and somewhat surprising.

    Divemedic · January 5, 2023 at 7:58 am

    The largest difference between a PA and an NP is the method of teaching. PAs are taught using the medical model, and NPs are taught under the nursing model. NPs are all AFAIK, Master’s degrees or higher. There are schools that graduate PAs with Associates degrees.
    Both can write prescriptions.
    PAs have to retake the licensing exam every five years in many states (I don’t know about all, and I don’t know about NPs)
    Both have to attend a number of hours of training to maintain their license. Doctors do not.
    NPs can open their own practice, PAs have to be a part of a doctor’s practice.
    NPs can, under some circumstances in some states prescribe controlled substances. PAs, as far as I know, cannot.
    I am sure there are other differences, but I can’t think of them now.

Grumpy · January 5, 2023 at 7:46 am

As a FNP (family nurse practitioner), I can tell you my side, and it isn’t pretty. Docs (MD/DO) will have a 4-7 year residency AFTER graduating med school, even for family practice (5 years here locally). NPs don’t get a post-grad residency. When I went through (1990s), an applicant had to have 5 years of bedside nursing experience. Those days are gone……follow the money.

Vanderbilt University had a class-action lawsuit filed against them in the late 90s. They had taken students without a nursing degree or license (I know of one that had a communications degree) and ran them through their NP program. Employers were smart enough to not hire these graduates, hence the class-action lawsuit (brought by the students…..who couldn’t get NP jobs).

The problem I’m seeing today for NPs is the rush through from basic nursing through to advanced nursing, without ANY bedside experience. While I’m happy to discuss and mentor new NPs in the advanced arena, I will NOT explain basic concepts that should have been learned at the bedside.

In my AO, there are no longer bedside requirements for NP applicants. Anecdotal only (yes, I know), but I’ve had multiple conversations with new NPs who don’t understand basic anatomy or physiology, much less pathophysiology.

    Divemedic · January 5, 2023 at 8:48 am

    The same happened to PA. It was supposed to be a way for Vietnam era combat medics with experience to become practitioners. To allow those years of experience to not be wasted.
    Now there are people with no experience becoming PAs, and it’s essentially become viewed by college students as the “fast way” to “practically a doctor”

Anonymous · January 5, 2023 at 8:43 am

I used to teach a chemistry class to mostly nursing students. It might not be medical, but it does a good job of weeding out people who don’t pay attention to detail and people who don’t pay attention to units of measurement. You can’t have nurses running around giving the wrong dose of medicine to patients.

    Divemedic · January 5, 2023 at 8:49 am

    That it is. I have taken the entire undergrad chemistry series. It can be difficult. Orgo absolutely sucked.

      it's just Boris · January 5, 2023 at 12:53 pm

      Some professors seem to deliberately make courses more miserable than they need to be; one theory my class came up with was, this is a way for them to reduce future competition for their job.

      OChem seems to be prone to this, although in fairness carbon is an incredibly versatile element, reaction-wise, with a truly bewilderingly rich range of interactions.

      Another one, from undergrad days, was high energy physics.

Exile1981 · January 5, 2023 at 9:45 am

Not being a medical time here is my thoughts. I’m a boiler inspector, to do my job i have 6 different licenses for inspecting different items and one is one provincial regulations. I am required to do 40hrs a year in continuing ed as part of keeping my licenses valid plus every 5 years i have to write a renewal exam to prove i am current on the regs.

I was talking to my family doctor and the requirements on staying current are significantly less than for my field with no renewal exams. I realize no one wants a boiler blowing up and taking out a school full of kids but i had always assumed doctors would be staying current more than they do.

    Divemedic · January 5, 2023 at 10:11 am

    That’s the odd part. Once you are a physician, there are virtually no legal licenses required to be renewed, and no continuing education required. I knew one doctor that was still writing prescriptions and orders in grains back in the early 2000’s.
    Now many hospitals and other organizations will require doctors to be board certified in one specialty or another, but that is a certification not a license.
    On the other hand, nurses, PAs, NPs, paramedics, technicians and the like require constant continuing education and certification in order to keep their licenses. I spent all day yesterday renewing three of my certifications.

      Exile1981 · January 5, 2023 at 11:57 am

      So its a 2 or 3 hour written exam for each of my licenses. Two are 5 year renewals ( so exam every 5 years) and 4 are on 3 year renewal cycles.

      That doesnt include all the ‘safety’ certifications i have to also renew every 3 years, each of which is usually a gull day class. 1st aid with cpr; confined space, confined space rescue, fall arrest, gas testing, SCBA cerification; Just the safety classes eat up over a week of work every 3 years

        Divemedic · January 5, 2023 at 12:43 pm

        I hear ya. Makes you wonder about certification for elected office.

          it's just Boris · January 5, 2023 at 12:55 pm

          Heh. Both in general, and then for subjects for which they are attempting to write laws and regulations.

          If only…

Aesop · January 6, 2023 at 3:42 pm

No matter how flat the pancake, there’s always two sides.

You forget that licensure came about at all because nursing used to be nothing but a dodge and rent check for washed up literal whores, with a mean IQ in the 70s.

Licensure requirements weed out the poor, but more importantly, it weeds out a lot of shiftless f**kheads. Not all of them – we all know several who snuck in somehow – but it keeps their percentages far lower than letting any-damned-body do it.

Licensure is a hurdle for douchebags that most of them cannot get over.

The Uses Of Licensure – Liberty's Torch · January 6, 2023 at 7:14 am

[…] Divemedic has written insightfully on the grift we call licensure. Indeed, he’s done so more than once. I’m confident that many who read those pieces will come away disturbed but not convinced. […]

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