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Mr. Johnson: Director, USMLE Step 3 Services, Federationof State Medical Boards; Mr. Austin: Senior Vice Presidentand Chief Operating Officer, Federation of State MedicalBoards; Dr. Thompson: President and CEO, Federation ofState Medical Boards, Dallas.

The opinions expressed in this article are those of the authorand not necessarily the views or policies of the Federation ofState Medical Boards.

Correspondence: David Johnson, Federation of State MedicalBoards, PO Box 619850, Dallas, TX 75261–9850; e-mail:djohnson@fsmb.org.

The Journal of Continuing Education in the Health Professions, Volume 25, pp. 183-189. Printed in the U.S.A. Copyright (c) 2005 TheAlliance for Continuing Medical Education, the Society for Medical Education, the Society for Academic Continuing Medical Education, andthe Council on CME, Association for Hospital Medical Education. All rights reserved.

Innovations in Continuing Medical Education

Role of State Medical Boards in Continuing Medical EducationDavid A. Johnson, MA; Dale L. Austin, MA; and James N. Thompson, MD

Abstract

The evaluation of physician competency prior to issuing an initial medical license has beena fundamental responsibility of medical boards. Growing public expectation holds that med-ical boards will ensure competency throughout a physician’s career. The Federation of StateMedical Boards (FSMB) strongly supports the right of state medical boards to require physi-cians to demonstrate continuing qualification for medical licensure. The FSMB viewscontinuing medical education (CME) as an important component of any maintenance-of-competence initiative. Most medical boards require CME as part of their license renewalprocess. Learner-focused CME with measurable outcomes enables the medical profession’semphasis on core competencies, training, and assessment, and the general public’s expecta-tion for maintenance of physician competence. To effectively move their licensee populationstoward the most effective CME tools and structure, medical boards must recognize physi-cians’educational needs and preferences. Medical boards can be proactive by fostering edu-cational consortia involving medical boards, medical societies, and academic medicalcenters and featuring educational sessions that represent the best in current CME practices.

Key Words: state medical boards, medical education, continuing maintenance of competence,educational consortium, license renewal, lifelong learning, medical education continuum

The greatest privilege that society bestows onany profession is the autonomy to self-regulate.This privilege comes with an equally importantresponsibility: to meet the public’s expectationthat the profession develop systems to assurethat practitioners maintain their competencethroughout the lifetime of their practice.1 Formuch of the latter half of the 20th century in thefield of medicine, this assurance has beendependent largely on participation in continuingmedical education (CME) that is administered

and/or mandated by various entities includinghospitals, medical societies, pharmaceuticalcompanies, medical schools, and state medicalboards.

In recent years consensus has emerged thatcontinuous learning through CME is not only animportant part of the professional life of everypracticing physician, but it can serve as anadjunct to ongoing initiatives for the mainte-nance of physician competence, throughout apractitioner’s career. A conjoint committee con-vened by the Council of Medical SpecialtySocieties (CMSS) and drawing together 13 med-ical organizations representing a cross-section ofmedical education, specialty, regulatory, andpractice communities began meeting in 2002 forthe purpose of “addressing the intellectual chal-lenges” facing the profession as it grappled withhow best to reposition CME.2 The resultingvision statement set forth 6 principles for effec-tive CME. Those principles are that CME forphysicians should enhance quality care, supportprofessional activities, assess professional and

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educational needs, evoke professionalism, andmotivate learners, all while producing measura-ble outcomes.2 This vision for CME involves thephysician as a learner and complements the corecompetencies identified by key stakeholders:“lifelong learning and self assessment,” by theAmerican Board of Medical Specialties(ABMS), and “practice-based learning andimprovement,” by the Accreditation Council forGraduate Medical Education (ACGME).3–5

Whether characterized as the physician-scholar,a “lifelong learner” or “practice-based learningand improvement,” the motif of the physician-learner is already taking root at all levels of pro-fessional development.6

State medical boards are accountable, inpart, for the lifelong learning and continuedcompetence of their physician licensees. Thiseducational continuum continues to deepen incomplexity and interconnectedness betweenstages (undergraduate, graduate, continuing),specialty certification, and medical licensure.Indeed, there is a growing realization amongmedical boards that their role in assuring theongoing competence of their physician licenseesis a natural extension of this continuum and themedical profession’s dedication to lifelonglearning of practitioners. Most medical licensingboards (47 of 69) already have an oversight rolein graduate medical education by virtue of thetraining or resident licenses they issue.7 Forty-two boards are empowered to take disciplinaryaction against physicians in residency programs;20 boards have mandatory reporting require-ments for residency programs regarding discipli-nary actions taken against residents.7 In somestates (for example, Kentucky and Nebraska),medical school deans serve automatically asmembers (sometimes ex officio) on their respec-tive licensing boards. Even the primary exami-nation for initial medical licensure (the UnitedStates Medical Licensing Examination) isembedded into the curriculum at most of thiscountry’s 125 allopathic medical schools, as apromotion or graduation requirement or both.8

There is a growing realization that issues oflicensure and CME touch equally on publicexpectations of competence and the medicalprofession’s shift toward competency assess-ment. This article attempts to outline the currentCME requirements of medical licensing boards,the role of the Federation of State MedicalBoards (FSMB), its policies regarding CME,and the potential role for CME in ongoing ini-tiatives relative to the maintenance of physiciancompetence.

State CME Requirements

State medical boards play a unique role in thecontinuum of medical education because they arethe only stakeholder bearing a statutory charge forthe protection of public health, safety, and welfarethrough the licensing, regulation, and disciplineof physicians.9 One of the fundamental responsi-bilities of a state medical board is assuring physi-cian competence before issuing a medical license.The license that medical boards grant is for thegeneral, undifferentiated practice of medicine,with license renewal required every 1 to 3 years.10

State medical boards routinely mandate CMEas part of the license renewal process under thestate’s medical practice act. Currently, 54 of thiscountry’s 69 licensing boards require CME forphysicians seeking license renewal. Thirty-eightof the boards mandating CME require that all, orpart, of the CME be either American MedicalAssociation (AMA) Category 1 or AmericanOsteopathic Association Category 1 or 2 credits.11

In addition, 24 medical boards will accept theAMA’s Physician Recognition Award (PRA) inlieu of CME.12 The actual requirement for CMEranges from as little as 20 credits annually to 150credits every 3 years. Medical boards monitorcompliance with CME requirements through ran-dom audits of license renewal applications.11,13

For medical boards that require CME oftheir licensed physicians, the underlying reasonsare plentiful. CME provides one means bywhich medical boards evaluate a physician’s

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commitment to continued competence and theprofession’s goal of lifelong learning. In addi-tion, required CME provides the public with evi-dence that their physicians are attempting to staycurrent in their knowledge and practice tech-niques. CME offers physicians an opportunity toobtain knowledge about specific treatments andpractices relevant to their own practice. Finally,CME can also be used for remediation of identi-fied areas of deficiency, a particularly importantconsideration if the board has quality-of-careconcerns about a physician’s performance. Inthese instances, it becomes critical that the CMEis tailored to address identified deficiencies, andthere are mechanisms for state boards to monitorphysician outcomes. Portions of this frameworkalready exist in the context of medical boards’use of national and/or regional physician assess-ment centers such as those currently operating inCalifornia, Colorado, and New York.

In recent years, some jurisdictions havebegun requiring that physicians obtain a certainnumber of CME credits related to a particulartopic, such as pain management or ethics.11

However, jurisdictions have been somewhatreluctant to require that the mandated CME beassociated with or related to the physician’sactual practice—a reticence perhaps stemmingfrom the undifferentiated (rather than specialty-specific) nature of the medical license. To date,only 2 licensing boards, Nevada’s medical andVermont’s osteopathic, require a minimum num-ber of CME credits applicable directly to a physi-cian’s specialty or area of focus for theirpractice.11 The need for specialty-specific orpractice-focused CME is mitigated somewhat inthe case of boards that recognize the AMA’s PRAas meeting their CME requirements. Because thePRA requires that a minimum of half the earnedcredits be in the physician’s specialty or area ofpractice, most medical boards achieve much thesame results as if they had formulated explicitrequirements around practice-focused CME.14

While there are merits to state medicalboards’ CME requirements, the weaknesses are

also apparent. State medical boards are ham-pered by limited resources and sometimes theabsence of any control over their operationalbudget and revenue. The result is state medicalboards’ reliance on random audits in monitoringCME, a mechanism that some would cite as anunacceptable extension of the “honor system”that has long characterized CME in this country.A recent case pending before the MarylandBoard of Physicians involves charges that one ofits licensees falsified his CME credits.15

Although relatively few cases of this natureoccur, it has led some to push for an outsideorganization to monitor physicians’ compliancewith CME. However, the absence of a centralrepository for tracking and reporting CME forall U.S. physicians hinders accountabilitybecause it leaves licensing boards and other cre-dentialing bodies reliant on self-reported infor-mation. A noteworthy exception, however, is theAmerican Academy of Family Physicians(AAFP), which maintains a primary source-ver-ified central repository for CME credit for itsmembers.16

Some would argue that a more fundamentalweakness arises from the failure of all state med-ical boards to adopt CME requirements as an ele-ment of license renewal. Some might point to thisomission as a missed opportunity on the part oflicensing boards toward achieving their goal ofensuring continuing competence of physicians.

FSMB and CME Policy

In 2001, the board of directors of the FSMB—the membership organization of this country’s69 medical licensing boards—approved a rec-ommendation to the Accreditation Council forContinuing Medical Education (ACCME)Content Validation Task Force to consider thefollowing elements in defining valid CME. Thatis, CME should

• Be evidence-based, scientific, current,objective, and presented in an unbiased format;

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• Have objective, measurable outcomes—that is, data evidencing positive practice changes;

• Promote the efficient and effective practiceof medicine in a physician’s area of expertise;

• Be a positive part of a physician’s practiceand involvement in lifelong learning and mainte-nance of competence;

• Promote quality health care by informingphysicians of what denotes quality;

• Be a tool to educate physicians aboutpotential errors and to promote safe practice; and

• Be a credible mechanism for public assur-ance of a physician’s continual maintenance ofcompetence.17

The recommendations focus on quality, com-petence, and the physician as learner. Two majorthreads run through the CME of the future: theshift toward competency-based assessment andassuring maintenance of physician competence.

The policy of the FSMB is unequivocal in itssupport of the right of state medical boards toensure that physicians demonstrate their “con-tinuing qualification for medical licensure” atthe time of license renewal. In large part, thisdemonstration is evidenced through requiringCME as a part of the license renewal process.10

Discussions of FSMB policy and recom-mendations to state medical boards inevitablyhighlight the strengths and limitations of theFSMB’s role in the field of medical licensureand regulation. As the national membershiporganization for state medical boards, the FSMBprovides a national voice for the medical regula-tory community on licensing and regulatory top-ics, including CME. FSMB policy, onceapproved by its membership at the organiza-tion’s annual meetings, often becomes a blueprint on which individual state medical boardscan address specific issues such as changes inCME requirements. At the same time, however,the FSMB is not a regulatory entity, and thus, itcannot mandate changes or reforms to the poli-cies of its membership. Instead, the FSMBbrings licensing board concerns and perspectives

to discussions of CME through its formal rela-tionships with key entities in the CME field; forexample, the ACCME designates the FSMB as 1of its 7 member organizations with an FSMBrepresentative serving on the ACCME board ofdirectors.18

CME and the Role of Maintenance ofCompetence

One complementary strategic initiative currentlyunder way involves the FSMB SpecialCommittee on Maintenance of Licensure, whichwas established in 2003. The charge to the com-mittee included evaluating the responsibility ofstate medical boards for ensuring physiciancompetence throughout the course of a physi-cian’s career and the efficacy of methods used tocarry out these responsibilities. In the area ofCME, the committee reviewed information pro-vided by the ACCME that pointed to the effec-tiveness of CME in changing knowledge andpractice, when CME is obtained as part of a sys-tem of continuous professional developmentinvolving self-assessment or self-reflection,remediation, and reassessment.19 Groups like theAMA, ACCME, the CMSS, and the AAFP areimplementing standards and systems theybelieve will transform traditional CME into anenterprise that measures the effectiveness of aneducational experience by its impact on physi-cian performance and patient care outcomes. Atthat level of physician practice, the credit nowoffered for performance improvement andInternet point-of-care activities may deservespecil recognition.20

As the FSMB continues its efforts to reeval-uate CME requirements as part of the ongoinginitiative pertaining to the maintenance of physi-cian competence, senior staff are meeting withleadership at both the AAFP and the AMAregarding recent changes in the CME credit sys-tem. The chair of the FSMB Special Committeeon Maintenance of Licensure serves on theABMS committee currently examining mainte-

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nance of certification. In turn, the ABMS chairserves on the FSMB Maintenance of LicensureCommittee. The latter has proved a particularlybeneficial move in light of the shift by theABMS’s 24 member boards toward a mainte-nance-of-certification model predicated in parton the need for physician lifelong learning andself-assessment.21

Clearly, CME has the potential to be aviable tool for ensuring ongoing physician com-petence, if it is part of a system of continuousprofessional development that includes self-assessment, remediation, and reassessment.Data suggest that CME can be effective inchanging knowledge and practice, whenobtained as a result of serious self-assessmenton the part of the physician.22 The interim reportof the FSMB’s Special Committee onMaintenance of Licensure affirmed the beliefthat CME, as currently mandated by state med-ical boards, helps to facilitate continued compe-tence.23 However, the committee felt that CME,as it is currently structured and utilized by statemedical boards, remains insufficient to verify orensure continued competence.

State Medical Boards and CME Consortia

Effective CME builds on the medical profes-sion’s commitment to lifelong learning and con-tinuous improvement. It does so by supportingthe continued professional development ofphysicians, conveying new information, andteaching new clinical skills that lead to changesin physician behavior and improved patient out-comes. Linking CME with changes in physicianperformance and patient outcomes has becomeincreasingly important in a rapidly changinghealth care knowledge environment.

In light of the current attention on patientsafety and ongoing physician competence, it isimperative for stakeholders—but especiallylicensing boards—to critically evaluate howCME can be restructured to better affect physi-cian performance and improve patient outcomes.

The 1998 report of the FSMB’s SpecialCommittee on Evaluation of Quality of Care andMaintenance of Competence made several rec-ommendations in this regard. The committeerecommended that state medical boards becomemore vigorous in sponsoring educational pro-gramming as one means of achieving continuedphysician competence. Because no initiative inthe house of medicine occurs in a vacuum, thecommittee also recommended that state medicalboards establish “a statewide consortium”involving undergraduate and graduate medicaleducation, the medical society, hospitals, healthcare organizations, and others to facilitate mean-ingful and appropriate CME programming.24

Initiatives such as an educational consortiumwill require state medical boards to think deeplyand proactively not simply about CME and itsrole in their license renewal process, but alsoabout the educational needs of their physicianlicensees and public expectations of physiciancompetence. If state medical boards are to avoidbeing perceived as simply a reactive entity, theymust continue to look for opportunities to leadproactively in those initiatives that mesh withtheir charge of public protection. That opportu-nity exists in the arena of CME reform. Providingmeaningful leadership in the area of CME mayrequire that state medical boards establish rela-tionships where they have not existed previously,while strengthening relationships in other areas.Medical societies, regional CME providers, andacademic medical centers are among the obviouschoices for such a relationship-building initiative.

In addition, such educational consortiarequire state medical boards to become moreconversant in the literature and recent develop-ments affecting CME nationally. Simply main-taining a requirement of X number of CMEcredits will not suffice to ensure continued com-petency for any jurisdiction’s practitioners. Statemedical boards must gain a firm understandingof the recent developments in the field, theevolving vision25 and evidence for “optimal”CME that is “self-directed”26 by the physician

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for “the purpose of improving [physician]knowledge, skills, and attitudes” leading tomeasurable outcomes in physician practice andpatient care.27 This may well be a task best car-ried out by a subcommittee of the licensingboard prepared to delve into the broader issuesof ongoing physician competence.

Reform of CME

For many physicians, what they seek in CME isreflective of former House Speaker TipO’Neill’s observation that “All politics is localand personal.” They want their CME “local”with options for learning from the privacy oftheir home or practice; they also want CME per-sonalized for relevance to their practice.28 To theextent that CME reform strives to achieve suchan ideal, state medical boards have a uniqueopportunity to assist in actualizing the goal.State medical boards willing to engage in the

arena of CME reform will find the dialoguestimulating and the challenges significant. Thereward, however—a system of CME that com-plements the licensing boards’ mission of publicprotection—will far exceed the difficultiesinherent in the journey.

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2. Alliance for Continuing Medical Education.Report of the Conjoint Committee on Contin-uing Medical Education, March 2002.Reforming and repositioning continuing med-ical education. Available at: http://www.acme-assn.org/files/RRCME.doc. Accessed May 12,2005.

3. Accreditation Council on Graduate MedicalEducation. Core competencies document.Available at: http://www.acgme.org/outcome/comp/compMin.asp. Accessed May 17, 2005.

4. American Board of Medical Specialties.Maintenance of certification document.Available at: http://www.abms.org/Downloads/Publications/1-What%20is%20MOC.pdf.Accessed May 17, 2005.

5. American Osteopathic Association. Core com-petencies document. Available at: http://do-online.osteotech.org/pdf/acc_cccppart1.pdf.Accessed May 17, 2005.

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8. Association of American Medical Colleges.Curriculum directory of United States medicallicensing examination requirements. Availableat: http://services.aamc.org/currdir/section1/start.cfm. Accessed July 2, 2005.

9. Federation of State Medical Boards. Elementsof a modern state medical board. Dallas:Federation of State Medical Boards, 1998.

Lessons for Practice

• Most state medical boards mandateCME (sometimes content specific) aspart of the license renewal process.

• As currently structured and used bystate medical boards, CME remainsinsufficient to ensure or verify contin-ued competence.

• Practice-specific CME can support themaintenance of physician compe-tence.

• State medical boards should partner ineducational consortiums to fostermeaningful CME for licensees.

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10. Sigel ME, Smith LE. A guide to the essentialsof a modern medical practice act. Dallas:Federation of State Medical Boards, 2003.

11. Federation of State Medical Boards. CMErequirements table [unpublished]. Dallas:Federation of State Medical Boards, 2005.

12. American Medical Association. AMA physi-cian recognition award. Available at:http://www.ama-assn.org/ama/pub/cate-gory/2922.html. Accessed July 3, 2005.

13. American Medical Association. State medicallicensure statistics and requirements, 2005.Chicago: American Medical Association,2005, pp. 46-47.

14. American Medical Association. Physicianrecognition award. Available at: http://www.ama-assn.org/ama/pub/category/2927.html.Accessed on July 2, 2005.

15. Connolly C. Medicare official fined $20,000.Washington Post, June 4, 2005, p. A3.

16. American Academy of Family Physicians.Available at: http://www.aafp.org/cme.xml.Accessed May 28, 2005.

17. Federation of State Medical Boards’ Board ofDirectors, meeting July 21, 2001, San Diego,California.

18. Accreditation Council for Continuing MedicalEducation. Available at: http://www.accme.org/index.cfm/fa/about.directors.cfm.Accessed July 5, 2005.

19. Robertson MK, Umble KE, Cervero RM.Impact studies in continuing education forhealth professions: update. J Contin EducHealth Prof 2003; 23:146-156.

20. American Medical Association. Standards fordesignating AMA PRA Category 1 credit onperformance improvements and Internet point

of care. Available at: http://www.ama-assn.org/ama/pub/category/13151.html and http://www.ama-assn.org/ama/pub/category/15085.html. Accessed July 3, 2005.

21. Batmangelich S, Adamowski S. Maintenanceof certification in the United States: a progressreport. J Contin Educ Health Prof 2004;24(3):134-138.

22. Davis DA, O’Brien MA, Freemantle N, WolfFM, Mazmanian PE, Taylor-Vaisey A. Impactof formal continuing medical education: doconferences, workshops, rounds, and othercontinuing medical education activities changephysician behavior or health care outcomes?JAMA 1999; 282(9):867-874.

23. Kopelow M. CME in the context of continuingphysician development in 2003 and beyond.December 2003 meeting of the Federation ofState Medical Boards’ Special Committee onMaintenance of Licensure.

24. Martin MJ. Report of the special committeeon evaluation of quality of care and mainte-nance of competence. Dallas: Federation ofState Medical Boards, 1998.

25. Bennett NL, Davis DA, Easterling WE Jr, etal. Continuing medical education: a newvision of the professional development ofphysicians. Acad Med 2000; 75:1167-1172.

26. Mazmanian PE, Davis DA. Continuing med-ical education and the physician as a learner:guide to the evidence. JAMA 2002;288(9):1057-1060.

27. Shojania KG, Grimshaw JM. Evidenced-basedquality improvement: the state of the science.Health Aff (Millwood) 2005; 24(1):138-150.

28. Conti CR. Cardiovascular continuing medicaleducation: what education do you want? ClinCardiol 2002; 25:491-493.