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As states proceed toward maintenance of licensure programs, MOC may acquire a second role for dermatologists

Ten years after the Federation of State Medical Boards (FSMB) began discussing the notion of ongoing physician competency, a handful of state boards have started conducting pilot projects to determine how best to implement Maintenance of Licensure (MOL). By the time the first state medical board (SMB) is ready to adopt MOL, dermatologists will likely be comfortable with the new paradigm of lifelong learning, continuous professional development, and maintenance of certification (MOC) and all that they entail.

States will likely try to implement a system for licensure that won’t have a dramatic effect on the physician workforce, which is already being tested in the wake of health care reform, according to Robert S. Kirsner, MD, PhD, vice chair of dermatology at the University of Miami Miller School of Medicine and chair of the American Academy of Dermatology’s Council on Education and Maintenance of Certification. States won’t want to lose any more physicians who might think that MOL is too arduous of a process and will either opt to retire early or retreat from patient care.

MOL rolls out

“From the beginning, we have taken an iterative and methodical approach to MOL. We want to be evolutionary in our approach, not revolutionary,” noted FSMB President and CEO Humayun J. Chaudhry, DO, MS. “There’s no need or desire to shock the system.”

Even before adopting a framework for MOL two years ago, FSMB has been working with key organizations involved in medical education and assessment including the American Medical Association, the American Osteopathic Association (AOA), the American Board of Medical Specialties (ABMS), the AOA’s Bureau of Osteopathic Specialists, the Council of Medical Specialty Societies, the Accreditation Council for Continuing Medical Education, the National Board of Medical Examiners, and the National Board of Osteopathic Medical Examiners. These groups, among others, have representatives on the FSMB’s MOL Implementation Group and its CEO Advisory Council. The exchange of information is not only to inform, but to obtain input and insight, Dr. Chaudhry said. [pagebreak]

Its biggest stakeholders, of course, are the nation’s 70 state medical boards that comprise the FSMB. (Some states have separate allopathic and osteopathic boards.) The challenge is to create an approach to MOL that is simple enough to appeal to all SMBs, yet substantial enough that medical licensure remains meaningful. It doesn’t make sense to have 70 different approaches, especially knowing that one-quarter of all physicians have more than one state license, Dr. Chaudhry said. But it does make sense to have an approach that is more similar than not across all SMBs. With SMBs around the country looking to implement MOL, Dr. Kirsner is optimistic a spectrum of approaches that will lead to best practices will emerge.

Once they emerge, SMBs may want to spend a year educating their doctors and the public about how they will implement MOL and why, Dr. Chaudhry said. Then each component of MOL can be phased in during the course of two or three years. Some SMBs, however, may choose to streamline the process. “The FSMB is providing guidelines,” he said, “but it’s entirely up to the state as to what it wants to do.”

Pilot projects

To that end, the first pilot project — a survey of SMBs to determine their readiness to begin participating in MOL — was launched in September. A second survey will launch soon that will determine what types of activities, beyond continuing medical education (CME), physicians engage in to keep their knowledge and skills current. Once the survey results are in, the SMBs will engage in more pilot projects to better determine how to move forward, Dr. Chaudhry said. [pagebreak]

The nine SMBs expected to engage in pilot projects include the Osteopathic Medical Board of California, Colorado Medical Board, Delaware Board of Medical Practice, Iowa Board of Medicine, Massachusetts Board of Registration in Medicine, Mississippi State Board of Medical Licensure, Oregon Medical Board, Virginia Board of Medicine, and Wisconsin Medical Examining Board.

Meanwhile, other SMBs are beginning to look at what steps they need to take and what resources they have or will need to implement MOL, he explained. As an example, some states may have to make modifications to their licensing rules to incorporate MOL. In Minnesota, state delegates adopted a resolution to accept participation in ABMS’ Maintenance of Certification (MOC) and the AOA’s Osteopathic Continuous Certification (OCC) as an acceptable means of meeting CME requirements for license renewal. “The hope is that other SMBs will do the same,” he said.

Because MOC and OCC are so robust, FSMB maintains that physicians engaged in either program should be recognized as being in substantial compliance with MOL, Dr. Chaudhry said. However, he is quick to note that neither specialty licensing nor recertification is a requirement to meet MOL, adding that “FSMB has always been focused on basic minimum competencies.”

In addition to meeting the three MOL components (see sidebar), medical licensure renewal will most likely continue to require payment of a licensure fee and submission of demographic data as mandated by state law. [pagebreak]

Impact on dermatologists

To critics who argue that MOL will be burdensome to physicians, Dr. Chaudhry says that the vast majority already engage in activities to keep their knowledge and skills current, and that many of these activities are applicable to their fulfillment of MOL. Among these activities are practice-relevant CME courses that emphasize performance improvement (PI) and use pre- and post-testing, hospital credentialing processes, the ABMS’ Patient Safety Improvement Program, and the AOA’s Clinical Assessment Program (CAP). Organizations, such as the Institute for Healthcare Improvement, also offer applicable programs.

“Just about every specialty society we’ve been talking to offers these types of activities,” he noted. For example, both the AAD’s Performance Improvement CME (PI CME) activities and the American Osteopathic Board of Dermatology’s (AOBD) CAPs are Web-based modules designed for assessing performance in the care of acne, atopic dermatitis, and melanoma. (Learn more about PI CME activities at

Physicians who are neither board-certified in a specialty nor participating in MOC or OCC as they are voluntary programs, as well as those working in non-clinical roles, can also engage in these options. “Any activity physicians engage in that improves their area of practice, and impacts their ability to be more knowledgeable and skilled, is going to count,” said Dr. Chaudhry, who added that the FSMB is working with SMBs to develop guidelines for activities that can be used by physicians for MOL purposes. [pagebreak]

Given that FSMB has indicated that MOC substantially complies with MOL, Thomas D. Horn, MD, MBA, who will become executive director of the American Board of Dermatology (ABD) in January, does not expect MOL compliance to have a significant impact on the majority of dermatologists. “We’re happy that the ABD can provide a resource for dermatologists to meet their MOL requirements and that it’s already in place,” he said. “I expect that dermatologists will just have to fill out an attestation and send it to their state medical board.” Practicing dermatologists who are lifetime certificate holders have the option to participate in MOC if they wish to use it to satisfy MOL requirements, he said.

Stephen Purcell, DO, chair of the AOBD, concurs. “In 10 years, most dermatologists will be well into continuous certification with either OCC or MOC, so I don’t think that meeting MOL requirements will have a significant impact on them.”

With MOL several years away from being adopted, dermatologists should keep a watchful eye on their SMBs as MOL evolves, Dr. Kirsner advised. “Lifetime certificate holders will want to be more vigilant because eventually they may have to do business a little differently,” he said. “For the majority of dermatologists, however, implementation of MOL will end up being seamless.” [pagebreak]

MOL Components

The following three components comprise Maintenance of Licensure (MOL), a method for ensuring ongoing physician competency promulgated by the Federation of State Medical Boards:

Reflective self assessment

(What improvements can I make?)

Physicians should participate in an ongoing process of reflective self-evaluation, self assessment, and practice assessment, with subsequent successful completion of tailored educational or improvement activities.

Assessment of knowledge and skills

(What do I need to know and be able to do?)

Physicians should demonstrate the knowledge, skills, and abilities necessary to provide safe, effective patient care within the framework of the six general competencies as they apply to their individual practice.

Performance in practice

(How am I doing?)

Physicians should demonstrate accountability for performance in their practice using a variety of methods that incorporate reference data to assess their performance in practice and guide improvement.

MOC Components

The following four parts comprise Maintenance of Certification (MOC), promulgated by the American Board of Medical Specialties in 2000:

Part I Licensure and Professional Standing

Medical specialists must hold a valid, unrestricted medical license in at least one state or jurisdiction in the United States, its territories, or Canada.

Part II Lifelong Learning and Self-Assessment

Physicians participate in educational and self-assessment programs that meet specialty-specific standards that are set by their member board.

Part III Cognitive Expertise

They demonstrate, through formalized examination, that they have the fundamental, practice-related, and practice environment-related knowledge to provide quality care in their specialty.

Part IV Practice Performance Assessment

They are evaluated in their clinical practice according to specialty-specific standards for patient care. They are asked to demonstrate that they can assess the quality of care they provide compared to peers and national benchmarks and then apply the best evidence or consensus recommendations to improve that care using follow-up assessments.

To learn more about MOC, visit

OCC Components

The following five components comprise Osteopathic Continuous Certification (OCC), developed by the American Osteopathic Association:

Component 1 Unrestricted Licensure

Requires physicians who are board-certified by the AOA to hold a valid, unrestricted license to practice medicine in one of the 50 states. In addition, they are required to adhere to the AOA’s Code of Ethics.

Component 2 Lifelong Learning/Continuing Medical Education

Requires all recertifying physicians to fulfill a minimum of 120 hours of CME credit during each three-year CME cycle though some certifying boards have higher requirements. Of these 120+ CME credit hours, a minimum of 50 credit hours must be in the specialty area of certification. Self-assessment activities will be designated by each of the specialty certifying boards.

Component 3 Cognitive Assessment

Requires the provision of one (or more) psychometrically valid and proctored examinations that assess a physician’s specialty medical knowledge, as well as core competencies in the provision of health care.

Component 4 Practice Performance Assessment, and Improvement

Requires that physicians engage in continuous quality improvement through comparison of personal practice performance measured against national standards for their medical specialty.

Component 5 Continuous AOA Membership

Requires physicians to have continuous membership in the professional osteopathic community through the AOA.



MOL Components
MOC Components
OCC Components