At least eight states in the past five years have approved rules governing what subjects doctors should study as part of their continuing medical education.
Carolyne Krupa, Feb. 13, 2012.
Alarmed by news of rising prescription drug abuse, Delaware Gov. Jack Markell in November 2011 told policymakers to take action to ensure physicians prescribe narcotics and other controlled substances only to patients who need them.
His solution? Require doctors to take continuing medical education on the subject.
■State-mandated physician CME subjects
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As a result, the Delaware Board of Medical Licensure and Discipline is drafting a rule mandating that doctors take CME every two years on prescribing controlled substances.
"Nationally, there is a significant problem of abuse of prescription medications -- particularly controlled substances -- and we were seeing that in Delaware as well," said James Collins, deputy secretary of state and director of the Delaware Division of Professional Regulation.
The new CME requirement is meant to keep Delaware physicians as educated as possible about prescribing these medications, he said.
65 of 70 U.S. medical licensing boards require CME for medical license renewal. Three other states have responded to prescription drug abuse with CME mandates in recent years. But that's not the only growing public health concern states are targeting. Despite strong opposition from physician organizations, states often react to headline-grabbing issues by trying to impose CME requirements on doctors.
At least 16 states mandate what CME subjects physicians must study. Of those, eight states have approved 14 new course requirements in the past five years. They come in response to a variety of issues, including domestic violence, the aging population and more awareness of the burdens of health disparities on minority communities.
Such laws often are enacted without much thought to their practicality or long-term viability, said Steven DeToy, director of government relations for the Rhode Island Medical Society. "As a result, we start having mandated CME du jour, with a new requirement for every topic people get excited about. It makes legislators feel good. It makes regulators feel good," he said.
CME is a well-established part of medical practice, said Humayun Chaudhry, DO, president of the Federation of State Medical Boards. The organization now known as the American Academy of Family Physicians was the first specialty to approve CME requirements for its members in 1947. The New Mexico Medical Board was the first to mandate CME as a licensing requirement in 1971. Today, 65 of the nation's 70 medical licensing boards require physicians to take CME to renew a medical license.
"CME increases a physician's knowledge, skill and competence and provides current information to keep up with new developments in medicine, which results in the improvement of their patients' health and well-being," said Dan Wood, spokesman for the Medical Board of California. "CME is just one of the ways we encourage physicians to be the best they can be."
Physician organizations staunchly object to legislators and policymakers -- for whatever their good intentions -- interfering with CME. The American Medical Association opposes state-mandated CME content and urges medical societies in states that have content-specific CME requirements to work toward having such rules rescinded or amended.
"The medical profession alone has the responsibility for setting standards and determining curricula in continuing medical education," AMA policy says.
At least 16 states mandate CME subjects for physicians. Mandated CME rules are particularly troublesome when they impose uniform requirements on all physicians, DeToy said. Rhode Island is a clear example of this, he said.
More than 15 years ago, the state enacted a law requiring physicians to take two hours of CME in bloodborne pathogens every two years. The law, in response to the AIDS epidemic, quickly caused problems as the mandated courses became repetitive and were irrelevant to some specialties.
Since then, the state has approved at least nine other subject areas -- including bioterrorism, medical ethics and palliative care -- that can be substituted for the bloodborne pathogen requirement to give physicians other options, DeToy said.
"Now there is a lot of talk about states pursuing these types of requirements for opiate prescribing, because that is the hot topic du jour, but I think we all know that when we put something into legislation, it is pretty hard to take out," he said.
In Massachusetts, rules took effect Feb. 1 that require physicians seeking to obtain a medical license or renew an existing one to complete at least three CME credits in pain management and opioid education, and two CME credits in end-of-life care. The opioid requirement is the result of legislation, and the end-of-life care rule was imposed by the Massachusetts Board of Registration in Medicine.
The Massachusetts Medical Society strongly opposed the rules, said Lynda Young, MD, the medical society's president. The penalty for not complying with the new law is forfeiture of licensure.
"We already have heard a lot of complaints from physicians who just think it's ridiculous that they have to do this," Dr. Young said. "We are concerned that physician competence is being defined by legislators or the board of medical registration. We really question why this is being applied to all physicians. Take a pathologist, for example. What do they need to know about opioid prescribing?"
Physician's crime leads to a mandate
Since April 2011, all doctors seeking licensure in Delaware have had to attest that they have received training on their obligations to report child abuse.
The requirement is the result of a serial child abuse case in the state. In August 2011, Earl Bradley, MD, of Lewes, Del., was sentenced to 14 life sentences without parole and an additional 160 years in prison after being convicted of multiple counts of assault and sexual exploitation of his young patients from 1998 to 2009.
Regulators are considering whether to make the mandated training part of the state's CME requirements, Collins said.
Meanwhile, the proposed rule requiring physicians to take CME for prescribing controlled substances would affect only physicians who prescribe such drugs, Collins said.
The Medical Society of Delaware is fighting the rule. "Prescription drug abuse is a complex, multifaceted issue, and it cannot be addressed simply through CME," said Mark Meister Sr., executive director of the Medical Society of Delaware.
The medical society opposes any mandated CME subjects. It's inappropriate for the political process to determine physician education, he said.
"The profession knows best what their educational needs and requirements are, and that can't be effectively legislated," Meister said.
State-mandated physician CME subjects
At least 16 states require physicians to take continuing medical education in specific subjects for medical licensure. How often physicians must take courses in the subjects and the number of credit hours required vary from state to state.
California: pain management, geriatric medicine, end-of-life care
Connecticut: infectious disease, risk management, sexual assault, domestic violence, cultural competence
Florida: MDs -- HIV/AIDS, prevention of medical errors, domestic violence; DOs -- HIV/AIDS, state laws and rules, professional and medical ethics, prescribing controlled substances, domestic violence, prevention of medical errors
Iowa: identifying and reporting abuse (for primary care physicians), chronic pain management, end-of-life care
Kentucky: domestic violence (for primary care physicians), HIV/AIDS
Massachusetts: pain management, opioid education (for physicians who prescribe controlled substances), end-of-life care, risk management
Nevada: medical ethics, weapons of mass destruction/bioterrorism, safe injection practices
New Jersey: cultural competency
New York: infection control, child abuse
Oklahoma: DOs -- prescribing controlled substances
Oregon: pain management and/or treatment of the terminally ill
Pennsylvania: patient safety, risk management
Rhode Island: bloodborne pathogens, universal precautions, bioterrorism, end-of-life care, Occupational Safety and Health Administration, medical ethics, pain management, infection control, modes of transmission or palliative care
Tennessee: prescribing controlled substances, pain management (for physicians who provide pain management)
Texas: medical ethics and/or professional responsibility
West Virginia: end-of-life care, pain management
Sources: American Medical Association, Federation of State Medical Boards and individual state medical boards
State Medical Licensure Requirements and Statistics, American Medical Association, 2012: catalog.ama-assn.org/Catalog/product/product_detail.jsp?productId=prod1910037
Continuing medical education overview by state, Federation of State Medical Boards, last updated Oct. 25, 2011: www.fsmb.org/pdf/grpol_cme_overview_by_state.pdf