The primary purpose of continuing medical education (CME) is to maintain and improve clinical performance to enhance patient outcomes. Although altruistic motivations may be present, there are some very practical reasons to pay attention to CME. A practitioner needs CME credits to maintain state medical licensure and specialty board-certification accreditation. Furthermore, CME compliance is a common condition of hospital medical staff membership and can impact participation in health plans.
In 2001, the New Jersey Legislature authorized the State Board of Medical Examiners (SBME) to establish requirements and standards for continuing education credits as a condition of the biennial renewal of physician licenses.1 Except for a few instances in which there is no mandated CME, such requirements exist throughout licensure systems in the United States.
Although keeping up with CME requirements, understanding the categories of credits and tracking credit hours can be time-consuming and can easily fall from the daily priority list, failing or forgetting to do these things can have a dramatic impact on professional licensure.
The Consequences of Non-Compliance
As explicitly set forth in the 2001 New Jersey regulation, the SBME may conduct random audits to determine licensee compliance with the CME requirements.2 The regulation further provides that failure to complete CME requirements or falsification of any information submitted on a renewal application is a basis for disciplinary action, which may result in penalties, including license suspension.3
The SBME has taken enforcement action based on CME shortfalls. In 2017, it acted against a licensee who failed to produce documentation of compliance during a random audit.4 In 2015, the SBME imposed discipline for failing to complete required CME credits in the biennial period with a license suspension until the credits were obtained.5 The SBME’s published disciplinary actions include other reports regarding CME non-compliance with penalties including financial penalties and reprimands. Much depends on the context in which the non-compliance manifests or is uncovered. In recent years, the SBME has posted disciplinary action results on its website under the “Disciplinary Actions” category available at www.njconsumeraffairs.gov/bme/Pages/actions.aspx.
Apart from the risk of random audits, the issue of CME compliance can come up in connection with various SBME investigations. Disciplinary inquiries include a review of CME compliance, either during the Preliminary Evaluation Committee meeting or in more formal proceedings. Although involvement in a disciplinary issue is unlikely for most practitioners, the reality of widespread malpractice litigation presents a different but related risk setting. Virtually every case involving a payment on a malpractice claim, whether by judgment after litigation or through negotiated settlement, is the subject of a review by the Medical Practitioner Review Panel. By statute, it receives a report of any such payment, and after evaluation of the matter, the Panel makes recommendations to the SBME for any further action. During its review, the inquiry includes confirmation of a practitioner’s CME compliance.
Keeping Up to Date
“To avoid the negative consequences of falling short on CME credits, it is important for all physicians to be aware when changes are made in the SBME credit requirements.”
To avoid the negative consequences of falling short on CME credits, it is important for all physicians to be aware when changes are made in the SBME credit requirements.
In 2005, for example, in accordance with a directive from the Legislature, the SBME added a requirement for continuing education concerning “cultural competency.”6 In 2011, a requirement was added for courses concerning end-of-life care.7 Most recently, in 2017, courses concerning prescription opioid drugs, including responsible prescribing practices, alternatives to opioids for managing and treating pain, and the risks and signs of opioid abuse, addiction and diversion, were added to the renewal requirement.8
In the hectic schedule of each day, it is easy to skip over these announcements of CME changes when they are made, but to protect your medical standing, you need to pay attention to them. Information regarding CME requirements is posted on the SBME website and is available through professional associations and publications.
Category I Credit and Category II Credit
In implementing regulations, the SBME draws from concepts and categories of credits developed and used in connection with the Physician Recognition Award (PRA) of the American Medical Association (AMA). These credits are generally referred to as Category I credit and Category II credit.* The regulations also recognize categories of medical education courses recognized by the American Osteopathic Association and the American Podiatric Medical Association.9
The standards for credit build on the foundational definition of “continuing medical education” adopted by the House of Delegates of the AMA:
CME consists of educational activities, which serve to maintain, develop, or increase the knowledge, skills, and professional performance and relationships that a physician uses to provide services for patients, the public or the profession. The content of CME is the body of knowledge and skills generally recognized and accepted by the profession as within the basic medical sciences, the discipline of clinical medicine and the provision of health care to the public.10
The distinction between Category I and Category II credits is developed in some detail in guidance from the AMA.11 These AMA categories are generally utilized in licensing systems across the country.
Category I: Broadly speaking, Category I credits are obtained by participating in certified activities sponsored by accredited CME providers. Completion of the activity entitles the physician to receive a certificate documenting participation. To qualify for Category I credit, an activity must meet seven core requirements: 1) It must conform to the definition of CME; 2) it must address an educational need, whether knowledge, competence or performance, that underlies the professional practice gaps that the learner might have; 3) it must present content appropriate in depth and scope for the intended learner; 4) the educational purpose or objective of the activity should be set forth; 5) it must utilize an appropriate learning methodology; 6) it must provide an assessment of the learner that measures achievement of the identified purpose or objective; and 7) it must be planned and implemented in accordance with standards regarding commercial support and independence. Approved activities can include live courses and seminar presentations or journal-based activities.
In 2005, the AMA Council of Medical Education approved credits for performance improvement platforms and a format of computer-based medical education called Internet Point-of-Care (PoC) learning.12 The latter new learning format provides medical providers with the opportunity to earn AMA PRA Category I Credit for consulting the medical literature online and applying their learning to their clinical practice. Use of the Internet took on increased importance during the coronavirus pandemic.13 Issues of MDAdvisor have regularly included published information qualifying for Category I CME Credit.
Category II: Category II activities are self-directed and do not generate any independent documentation. The requirements for Category II credit might be met with learning activities such as any of the following:
- Participation in activities that have not been certified for PRA Category I Credit
- Unstructured online searching and learning that do not qualify as Internet PoC
- Reading of authoritative medical literature
- Consultation with peers and medical experts
- Small group discussions
- Self-assessment activities.
This is not an exhaustive list. A practitioner could attempt to claim Category II credit for other varieties of learning. Most importantly, however, a Category II credit cannot be used to satisfy Category I credit requirements.
Recordkeeping and Documentation
The SBME has set the requirement for physician CME at 100 credits during the biennial term. Of these credits, at least 40 have to qualify as Category I credits. The balance can be satisfied with Category II credits. At the time of biennial renewal, the licensee certifies on the application that the required number of credits has been obtained, but this is done without specification. The regulation directs a licensee to maintain all evidence of the CME requirement being satisfied for a period of six years after completion of the credits and to submit documentation to the SBME upon request.14
The regulatory requirement to maintain documentation has been made easier with electronic storage and with many programs providing certificates of completion as PDFs. This may readily be done for Category I credits, a more labor-intensive system is required when a practitioner claims Category II credits for which no certificate is issued. The Medical Society of New Jersey has suggested keeping a log or journal with the information necessary to identify the activity and provides an example of such recordkeeping in its application for the MSNJ Physician Recognition Award Application.15 As modified for purposes of this article, that log has the following structure:
Date of Activity
Subject or Content Area
The CME standards, especially the recordkeeping requirements, provoke some predictable reactions. It is time-consuming and often expensive. But acting with an attitude of “Is it worth it?” or “Does anyone even check?” is a high-risk strategy.
A Lifelong Process
Demands on a practitioner’s time are substantial with obligations for patient care, clinics, operations and administrative meetings, not to mention family obligations. In a 1900 address, Sir William Osler said, “If the licence to practise meant the completion of his education how sad it would be for the doctor, how distressing to his patients! More clearly than any other, the physician should illustrate the truth of Plato’s saying—that education is a lifelong process.”16
It is often difficult to find time to recognize and address knowledge gaps or technical deficiencies. However, this is an extremely important part of lifelong learning as a physician, and commitment to being a lifelong learner is central to one’s existence as a professional. Moreover, the collateral consequences of complacency come with significant penalties for non-compliance.