American College of Emergency Physicians s3

1 PLEASE NOTE: THIS RESOLUTION WILL BE DEBATED AT THE 2012 COUNCIL MEETING. RESOLUTIONS ARE NOT 2 OFFICIAL UNTIL ADOPTED BY THE COUNCIL AND THE BOARD OF DIRECTORS (AS APPLICABLE). 1

2 3 4RESOLUTION: 25(12) 5 6SUBMITTED BY: Alabama Chapter 7 Delaware Chapter 8 Georgia College of Emergency Physicians 9 Iowa Chapter 10 Tennessee College of Emergency Physicians 11 Texas College of Emergency Physicians 12 Careers in Emergency Medicine Section 13 Emergency Medicine Workforce Section 14 Rural Emergency Medicine Section 15 16SUBJECT: Maintenance of Licensure 17 18 PURPOSE: Request the FSMB to substantiate that the maintenance of licensure program is necessary to 19 improve quality of care and patient safety, educate members on the impact of MOL on the practice of 20 emergency physicians and ED staffing, and inform the public on physician training and monitoring, including 21 state requirements for CME. 22 23 FISCAL IMPACT: Budgeted advocacy, public education, and communication activities. 24 25 WHEREAS, The American College of Emergency Physicians (ACEP) wishes to preserve the broadest 26possible career opportunities and the integrity of the specialty without undue professional limitations for its 27members, nor risk or diminish the value of the training and experience of its members; and 28 29 WHEREAS, The Federation of State Medical Boards (FSMB) will implement a series of Maintenance of 30Licensure (MOL) pilot programs in a number of states; and 31 32 WHEREAS, The purported reason for this new MOL program is to answer the concerns of the public that 33the public have some assurance the physicians caring for them have an appropriate level of skill and knowledge; 34and 35 36 WHEREAS, While comprehensive and robust research in support of a multi-component program for 37maintenance of licensure is not common knowledge among members of the ACEP; and 38 39 WHEREAS, Should a problem with a state’s current licensing program exist, a specific targeted 40individual state solution would be the more reasonable and cost effective approach; and 41 42 WHEREAS, There is a lack of evidence of an existing problem with the current system of licensing, there 43is a lack of evidence that such a comprehensive program as the MOL is the appropriate way to address a 44perceived problem should it exist, and any such effort increases the probability of increased time and financial 45burdens on our members; and 46 47 WHEREAS, such sweeping change initiated by the FSMB further infringes on the individual sovereignty 48of the states; and 49

3 4Resolution 25(12) Maintenance of Licensure 5Page 2 6 50 WHEREAS, There is a significant workforce shortage in emergency medicine and the implementation of 51MOL by some states may lead to emergency physicians migrating to states that have not adopted the MOL and 52this migration would worsen the workforce in participating states; and 53 WHEREAS, ACEP agrees the public should have reasonable assurance that emergency physicians have 54an appropriate level of skill and knowledge, ACEP is not convinced that such a sweeping change as the MOL 55program proposed by the FSMB is the necessary or appropriate response to address the public’s concerns; 56therefore be it 57 58 RESOLVED, That ACEP request the Federation of State Medical Boards to substantiate, with evidence- 59based data, that the Maintenance of Licensure program is necessary to improve quality of care and patient safety; 60and be it further 61 62 RESOLVED, That the Federation of State Medical Boards be requested to show that worsening of the 63current workforce shortage in emergency medicine will not occur as a result by the implementation of 64Maintenance of Licensure; and be it further 65 66 RESOLVED, That ACEP educate members on the history, current status, and possible future impact of 67Maintenance of Licensure on the practice of member physicians and staffing of the nation’s emergency 68departments; and be it further 69 70 RESOLVED, That ACEP inform the public on the current rigors of physician training, monitoring, and 71the facts regarding individual state requirements for continuing education available to physicians to improve their 72level of skill and knowledge and to maintain their license to practice medicine or osteopathic medicine. 73 74 75Background 76 77This resolution calls for the College to request the Federation of State Medical Boards (FSMB) to substantiate that 78the maintenance of licensure (MOL) program is necessary to improve quality of care and patient safety and that 79the FSMB show that worsening of the workforce shortage in emergency medicine will not occur with 80implementation of MOL. The resolution also calls for ACEP to educate its members on the impact of MOL on the 81practice of member physicians and emergency department staffing, and that ACEP inform the public on physician 82training and monitoring, including state requirements for continuing medical education (CME). 83 84 The FSMB online MOL information center states that: As medicine continues to rapidly evolve and grows 85 more complex, the need for lifelong learning and skills maintenance has increased. Research suggests 86 physicians may develop deficits in important skills and knowledge the further away they get from medical 87 school and residency training. 88 In contrast to the rigorous standards for initial licensure, however, state boards have historically had fewer 89 requirements to ensure that licensed physicians demonstrate their skills throughout their professional careers. 90 In most states, physicians must show that they have obtained a certain amount of CME credits, but they are 91 not required to get these credits in areas specifically related to their practices -- nor are they required to 92 demonstrate to their licensing boards what they have learned from such CME activities. 93 MOL provides a needed alternative to our current system, offering a framework that requires physicians to 94 demonstrate skills and knowledge in their areas of practice on an ongoing basis – throughout their careers. 95 96MOL promotes lifelong learning and continuous professional development, and is comprised of three 97components: reflective self-assessment, assessment of knowledge and skills, and performance in practice. 98According to the FSMB, MOL will be integrated and coordinated with activities of other accrediting and 99educational organizations to ensure there is no overlap or redundancy between their requirements and the FSMB’s 100requirements. 101 102The FSMB cites research to support the rationale for MOL, including studies relating to clinical experience and 103its relationship to quality of care, CME, continuous professional development, public perceptions and 7Resolution 25(12) Maintenance of Licensure 8Page 3 9 104expectations of physicians, physician surveys, quality of care, self-assessment, specialty board certification, and a 105national dialogue calling for physicians‘ greater accountability to the public. Citations may be found at: 106http://www.fsmb.org/m_mol_research.html. 107 108In the 2010 Journal of Medical Regulation (Vol 96, n4), the authors state that “while unequivocal, comprehensive 109and robust research in support of a multi-component program for MOL is not yet available because no medical 110regulatory authority has fully implemented such a plan, there is growing evidence in the medical literature about 111the practice of physicians over time, and the value of enhanced CME or continued professional development.” 112 113For example, studies indicate that practicing physicians who perform a lower volume of clinical or surgical 114procedures or who have less experience with specific conditions or diseases have higher rates of complications 115compared with their physician colleagues. 116 117In the 2005 “Systematic Review: The Relationship Between Clinical Experience and Quality of Health Care” 118Choudhry and colleagues found that “physicians who have been in practice longer may be at risk for providing 119lower quality care and that this subgroup of physicians may benefit from quality improvement interventions.” 120 121Regarding enhanced CME and continuing professional development (CPD), the Johns Hopkins Evidence-based 122Practice Center for Healthcare Research and Quality conducted a systematic review of the effectiveness of such 123education and reported in 2009 that multi-media, multiple instruction techniques and multiple exposures to 124content were associated with improvements in physician knowledge. There is also evidence that such CME/CPD 125practices are effective in changing physician performance. 126 127Other rationale for MOL medical regulation includes the contention noted by the FSMB that “profligacy in the 128care of one patient within an increasingly cost-contained health care system or organization could lead to less 129adequate care for another patient.” Another impetus for state boards to embrace changes is the concern that “if 130they don’t, others will.” 131 132The FSMB states that it is working closely with the American Board of Medical Specialties (ABMS), the 133National Board of Medical Examiners (NBME), the Accreditation Council for Continuing Medical Education 134(ACCME), the American Medical Association (AMA), the American Osteopathic Association (AOA), and the 135National Board of Osteopathic Medical Examiners (NBOME) to ensure that MOL minimizes burdens for 136physicians. 137 138The FSMB’s implementation group (IG) noted that nearly half of U.S. physicians already fulfill the intent of 139MOL through participation in the continuous specialty certification programs of the ABMS and the American 140Osteopathic Association Bureau of Osteopathic Specialists (AOA BOS). The MOL, maintenance of certification 141(MOC) and osteopathic continuing certification (OCC) are similar but not identical in purpose or design. While 142they each require lifelong learning and self-assessment, MOL does not require specialty board certification. For 143physicians who were never specialty certified or who are not interested in MOC or OCC, the FSMB states that it 144will help state boards identify activities that physicians already engage in, such as accredited CME, that could 145help them comply with MOL’s three components. 146 147Because 22.7 percent of physicians have more than one state medical license, the IG advised state boards to 148“strive for consistency in the creation and execution of state-based MOL programs across the country.” (MOL: 149Evolving from Framework to Implementation; Journal of Medical Regulation, Vol 7, n4) 150 151In 2011, the FSMB, the NBME, the NBOME, the ABMS, and the AOA BOS convened a meeting to explore 152ways to develop and design pilot projects/specific methodologies for state medical boards to consider as they 153implement MOL. Twelve state boards indicated an interest in implementing pilot projects. 154 155At the AMA’s 2012 annual meeting, delegates adopted policy urging medical boards to establish “flexible 156medical licensure requirements that benefit – and don’t harm – physicians.” The AMA wants to ensure that the 157FSMB mandates not become burdensome and says, “No doctor should be barred from practice for not keeping up 158with board certification requirements.” The AMA is urging licensing boards to “develop alternatives for the 10Resolution 25(12) Maintenance of Licensure 11Page 4 12 159estimated 200,000 physicians who are not board certified.” For physicians who are board certified the AMA is 160working with the FSMB and the ABMS to ensure MOC and OCC requirements are accepted as meeting MOL. 161 162FSMB CEO Humayun Chaudhry, DO, MS, FACP, FACOI, stated that the FSMB will not force physicians to be 163board certified nor will it require specialty certification, MOC or OCC as a condition of licensure. While the 70 164individual state medical boards will develop their own requirements for MOL, the FSMB is “developing 165standardized guidelines to help in the process.” (AMA News July 9, 2012). 166 167ACEP has maintained a liaison to the FSMB for many years. The representative attends the annual meeting each 168year. MOL information and resources may be accessed at: http://www.fsmb.org/mol.html. 169 170ACEP Strategic Plan Reference 171 172Develop and implement solutions for workforce issues. 173 174Fiscal Impact 175 176Budgeted advocacy, public education, and communication activities. 177 178Prior Council Action 179 180None 181 182Prior Board Action 183 184April 2012, reaffirmed the policy statement “The Role of the Legacy Emergency Physician in the 21st Century.” 185Originally approved June 2006. http://www.acep.org/Content.aspx?id=29822 186 187April 2012, reaffirmed the policy statement “Emergency Medicine Training, Competency and Professional 188Practice Principles.” Revised and approved January 2006; originally approved November 2001. 189http://www.acep.org/Clinical---Practice-Management/Emergency-Medicine-Training-Competency-and- 190Professional-Practice-Principles-Position-Statement.aspx 191 192 193Background Information Prepared By: Marjorie Geist, RN, PhD, CAE 194 Academic Affairs Director 195 196Reviewed by: Marco Coppola, DO, FACEP, Speaker 197 Kevin Klauer, DO, EJD, FACEP, Vice Speaker 198 Dean Wilkerson, JD, MBA, CAE, Council Secretary and Executive Director