Maintenance of licensure: supporting a physician's commitment to lifelong learning.

Initially focused on preventing the unlicensed practice of medicine by “quacks” and “charlatans,” state medical boards evolved necessarily over time to promote higher standards for undergraduate medical education; require assessment of knowledge and skills to qualify for initial licensure; develop and enforce standards for professional discipline; and, beginning in 1971, promote continuing medical education (CME). More than a century ago, state medical boards were instrumental in securing legislation that authorized them to refuse to examine graduates of poor-quality medical schools—even before the 1910 publication of Abraham Flexner’s scathing indictment of proprietary schools, which hastened their demise and closure (1, 2). Twenty years ago, the Federation of State Medical Boards (FSMB) partnered with the National Board of Medical Examiners to create the 3-step United States Medical Licensing Examination (which includes a clinical skills component added in 2004) as a qualifying examination for initial licensure accepted by all state medical boards (osteopathic physicians typically take the Comprehensive Osteopathic Medical Licensing Examination of the National Board of Osteopathic Medical Examiners). When the FSMB’s House of Delegates voted in 2010 to adopt a framework for maintenance of licensure (MOL), it was a seminal event because the primary focus of medical licensure up to that point had been the rigorous sequence of decision points and milestones—from admission into medical school through postgraduate training—that lead to the initial privilege to practice medicine. Although CME was first required for licensure renewal in New Mexico in 1971, and nearly all state medical boards now require a prescribed number of CME credit hours (and sometimes content-specific CME), the process by which physicians maintain their license has remained a concern among policymakers and regulators, particularly as the knowledge and skills needed to practice medicine grow exponentially. The MOL framework helps address these concerns by envisioning 3 components (reflective selfassessment, assessment of knowledge and skills, and performance in practice) that would be periodically required of actively licensed physicians in their area of practice in order for them to renew their license. The earliest calls to reform licensure renewal date back to 1967, when the National Advisory Commission on Health Manpower recommended that “state governments . . . explore the possibility of periodic relicensing of physicians and other health professionals” (3). In a report 4 years later, the U.S. Department of Health, Education, and Welfare (now the Department of Health and Human Services) noted that state boards provide a de facto lifelong medical license to most physicians and that state requirements were adequate as safeguards for entry into the profession but ineffective against “professional obsolescence” (4). These recommendations encouraged state medical boards to eventually adopt CME requirements. In more recent years, the Pew Charitable Trusts and the Institute of Medicine separately called for “continuing competency requirements” and “a mechanism to ensure that practitioners remain up to date with current best practices” to improve patient safety and reduce medical errors (5–7). With a national shortage of physicians and more than 30 million people soon eligible for health insurance under the Patient Protection and Affordable Care Act, striking the right balance between what is necessary to protect the public and promote quality health care—the primary mission of state medical boards—and what will be administratively reasonable for practicing physicians to demonstrate their commitment to lifelong learning without substantively disrupting patient care has been a priority of the FSMB and its state boards as they consider the specific means by which physicians will be able to meet MOL requirements. A series of guidelines adopted alongside the MOL framework has guided these deliberations (Table).