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Maintenance of Licensure: Supporting a Physician's Commitment to Lifelong Learning

Humayun J. Chaudhry, DO, MS, SM; Lance A. Talmage, MD; Patrick C. Alguire, MD; Frances E. Cain, BA; Sandra Waters, MEM; and Janelle A. Rhyne, MD, MA
[+] Article, Author, and Disclosure Information

From the Federation of State Medical Boards, Euless, Texas; South East Area Health Education Center, Wilmington, North Carolina; American College of Physicians, Philadelphia, Pennsylvania; and University of Toledo, Toledo, Ohio.

Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M12-0364.

Requests for Single Reprints: Humayun J. Chaudhry, DO, MS, SM, Federation of State Medical Boards, 400 Fuller Wiser Road, Suite 300, Euless, TX 76039.

Current Author Addresses: Dr. Chaudhry, Ms. Waters, and Ms. Cain: Federation of State Medical Boards, 400 Fuller Wiser Road, Suite 300, Euless, TX 76039.

Dr. Talmage: University of Toledo, 45 Exmoor, Ottawa Hills, OH 43615.

Dr. Alguire: American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106.

Dr. Rhyne: South East Area Health Education Center, 1601 Doctors Circle, Wilmington, NC 28401.

Author Contributions: Conception and design: H.J. Chaudhry, P.C. Alguire.

Analysis and interpretation of the data: H.J. Chaudhry, S. Waters.

Drafting of the article: H.J. Chaudhry, J.A. Rhyne, S. Waters.

Critical revision of the article for important intellectual content: H.J. Chaudhry, P.C. Alguire, S. Waters, F.E. Cain.

Final approval of the article: H.J. Chaudhry, J.A. Rhyne, P.C. Alguire, L.A. Talmage, F.E. Cain.

Administrative, technical, or logistic support: L.A. Talmage.

Collection and assembly of data: J.A. Rhyne, S. Waters.

Ann Intern Med. 2012;157(4):287-289. doi:10.7326/0003-4819-157-4-201208210-00478
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In 2010, the Federation of State Medical Boards adopted a framework for Maintenance of Licensure (MOL) under which actively licensed physicians will be required to periodically participate in a program of continuous professional development in order to renew their license. This commentary describes how the framework is likely to be implemented and discusses recommendations about a timeline for MOL and implementation as well as pilot implementation projects under way.

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You Cannot Be Serious
Posted on June 26, 2012
Marc S. Frager MD
East Coast Medical Associates
Conflict of Interest: None Declared
While the maintenance of licensure sound acceptible superficially, is it really reasonable to implement a costly and highly controversial procedure, like maintenance of certification, that has never been shown to have any value over and above continuing medical education? There is a vast number of publications pointing out the real problems with MOC including, cost, time commitment, and the fact the secure test seems to exist only to provide revenues to the testing organization. Until the MOC procedure has been compared in age matched physicians to current methods of CME and has been found to positively effect some worthwhile parameter of physician practice and behavior, this faulty mechanism of MOC should be discarded. Unfortunately that study does not currently exist.
Maintenance of Licensure (MOL): a Lifelong Commitment to learning or a Simply a Strategy to Support the Income of Some Organizations
Posted on July 13, 2012
Paul Kempen, MD, PhD
Conflict of Interest: None Declared

The article by Chaundhry and colleagues was written by 5 people with financial relationships with the Federation of State Medical Boards (FSMB), and one person who works for the American College of Physicians (ACP). (1) Both organizations are heavily invested in selling the requisite materials for MOC/MOL to physicians. In my opinion, the article is little more than an unpaid advertisement for their corporate programs of board certification (which already consumes over $400 million in gross receipts annually), which practicing physicians do not want or need and which have yet to be demonstrated to be of any proven value to patients. My concern is that the FSMB, ACP, ABMS and affiliates are non governmental agencies without legal authority striving to enforce this lucrative agenda to earn heavily on programs that support MOC/MOL, in this difficult economy. The CEOs of the ABMS boards with the longest history of 10 year recertification cycles each earn around $1 million annually-well above practicing physician’s working in their specialties- and these boards are associated with significant net worth as found in IRS 990 forms. These facts, when reviewed document the financial stakes for these programs and their leadership. When I questioned why the Annals of Internal Medicine chose to publish this article, Dr. Laine, Annals editor, wrote in a personal communication: “Annals was specifically interested in having authors involved in developing the MOL process to write on the topic to educate readers about how this would evolve in coming years.”

The common interests and leadership of many state medical boards and FSMB leaders, as well as in many specialty organizations and ABMS specialty Boards, requires an opposing and formal presentation of issues here, to reveal that this will be a battle in state legislators, where the law of MOL is seated:In Ohio (the first state in which FSMB is attempting to pilot MOL), the Ohio State Medical Society and other physician groups have resolved in 2012, to oppose the attempts of Dr Talmage and the FSMB to implement the MOL program with the force of law. Dr. Talmage, who chairs both the FSMB and State Medical Board of Ohio (SMBO)- is in a possibly very effective and possibly conflicted position. Accessing the SMBO’s own data for over 42,000 physicians, the SMBO (***) disclosed upon explicit request in a personal communication to me, that in 2011, only 5 physicians were subject to disciplinary action related specifically to incompetence with a total of 148 actions-a rather low rate by any measure. Two thirds of all actions resulted from drug or alcohol abuse, pill mill activities or other criminal offenses-rather than incompetence! CME requirements in Ohio are among the most demanding of all states, while some states require no CME. Ohio also leads states in the number of actions against physicians (suggesting either overzealousness or high rates of physician misbehavior-but NOT incompetence). Ohio is also a leader regarding freedom of information and online publication of Board activity to allow the extraction of data on the numbers of actions to which I here refer. (http://www.med.ohio.gov/).

MOL has existed for decades in all states and is not new. FSMB MOL is not inevitable or needed. Physicians need to unite, inform and oppose through their state legislators now. FSMB is implementing pilot projects in 11 states including: Ohio . Calif. , Colo. , Del. , Iowa , Mass. , Mississippi , Okla. , Ore. , Va. , and Wis. Detailed information and references for the above and most important facts can be found at http://www.youtube.com/watch?v=WRS15Dmsk7E and www.Changeboardrecert.com, including the financial data of all boards. Physicians must inform themselves and colleagues to take action in all states now, in this election year.

*** Sallie DeboltGeneral CounselState Medical Board of Ohio

Maintenance of Licensure
Posted on September 3, 2012
James J. Glazier, MD, FRCP
Wayne State University
Conflict of Interest: None Declared


I read with considerable interest Chaudhry et al’s (1) recent paper on maintenance of licensure(MOL). The authors note the considerable similarity between the MOL process and the Maintenance of Certification (MOC) process, required by members of the American Board of Medical Specialties (ABMS), including the American Board of Internal Medicine(ABIM). In particular, I was cheered to learn that the Federation of State Medical Boards (FSMB) MOL Implementation Group has recently recommended that physicians actively engaged in the MOC program of the ABMS or the American Osteopathic Bureau of Osteopathic Specialists be recognized as having fulfilled the requirements for MOL in any state. Indeed, if this recommendation is adopted, documentation of participation in an appropriate MOC program will be all be that is required to fulfill MOL requirements. As a physician continuously enrolled in the ABIM MOC program for the last 12 years, I find the above recommendation by the FSMB particularly sensible and appealing. While, over the years, I have developed an ever increasing appreciation of the excellent intentions and results of the MOC process (including improved patient care), the process can, at times, prove somewhat draining. The proposal of the FSMB, by enhancing recognition and appreciation of the ABIM MOC process and simplifying the MOL process, will likely make the MOC process more satisfying for many physicians already enrolled in the program. In addition, this proposal may pique the interest of a group of ABIM diplomates who have generally shunned the MOC process: those who obtained their ABIM certification before 1990, the so-called grandfathers (2). Accordingly, I would urge the American College of Physicians, the ABIM and all other members of the ABMS to support the above discussed proposal by the FSMB.


1.Chaudhry HJ, Talmage LA, Alguire PC, Cain FE, Waters S, Rhyne JA. Maintenance of licensure: supporting a physician’s commitment to lifelong learning. Ann Intern Med 2012;157: 287-9.

2. Glazier JJ. Recertification for grandfathers. Am J Med. 2011;124:e11

Maintenance of Licensure
Posted on September 9, 2012
Connie Nugent, Kenneth Nugent
Department of internal Medicine ,Texas Tech University Health Sciences Center, Lubbock
Conflict of Interest: None Declared
We read with interest the article on the maintenance of licensure (MOL) that appeared in the August 21, 2012, issue. The authors present a thoughtful analysis of components of the cognitive processes involved in continual medical education. In brief, they identify three components -- reflective self-assessment, assessment of knowledge and skills, and performance in practice. Their examples include participation in CME, completion of computer-based simulations, and patient / peer surveys. We suggest modifications which should clarify this process. The first component requires critical self-assessment of clinical skills and knowledge necessary for the physician’s current practice. This almost certainly involves more than participation in the usual CME activities and probably requires practice review and relevant testing (in effect, pretests). Based on this self-assessment, the next step involves identification of essential knowledge and skills which need improvement. Now follows a structured learning process that focuses on these specific skills. This activity is fundamental to maintenance of clinical skills and is not discussed by Chaudhry. The third component requires assessment of the self-study activities. This should include written tests using either a secure format or a timed case analysis format. This component also requires direct assessment of clinical practice using patient or peer surveys, direct observation, or structured medical record review. The fourth component requires a second round of reflective self-assessment, the identification of other areas needing improvement, directed study, and additional assessment. This four-step process continues indefinitely to improve decision-making, problem-solving, and patient care. The MOL process described by Chaudhry largely restates current requirements for licensure renewal based on required number of CME hours with the addition of a few, possibly one, practice assessment activities. In our view public schools in Texas have a better grasp of the critical thinking process that drives learning and education. The MOL process described by Chaudhry will not significantly improve the medical services currently provided in the United States. In addition, unlike Dr Glazier, we think the MOL will more likely undermine the ABIM recertification process than support it, since physicians will choose the easier route. As for the “grandfathers”, unless the state MOL requirements become very onerous, they will stick with reporting CME. Our recommendations emphasize continuous practice evaluation and acquisition of medical knowledge and skills. 1.Chaudhry HJ, Talmage LA, Alguire PC, Cain FE, Waters S, Rhyne JA. Maintenance of licensure: supporting a physician’s commitment to lifelong learning. Ann Intern Med 2012; 157: 287-9.
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