Following seven years of study, the FSMB House of Delegates in April 2010 adopted a framework by which actively licensed physicians in the United States will over time be expected to provide evidence every 5-6 years of participation in professional development and lifelong learning activities specific to their practice as a condition for medical licensure renewal. Through the work of a Special Committee and an Advisory Group during the last few years, the FSMB has developed recommendations to guide state medical and osteopathic boards in developing and implementing a framework for MOL:

As a condition of licensure renewal, physicians should provide evidence of participating in a program of professional development and lifelong learning that is based on the general competencies model:

• medical knowledge
• patient care
• interpersonal and communication skills
• practice-based learning and improvement
• professionalism
• systems based practice

The following requirements reflect the three major components of what is known about effective lifelong learning in medicine:

1. Reflective Self Assessment (What improvements can I make?)
   Physicians must participate in an ongoing process of reflective self-evaluation, self-assessment and practice assessment, with subsequent successful completion of tailored educational or improvement activities.
2. Assessment of Knowledge and Skills (What do I need to know and be able to do?)
   Physicians must 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.
3. Performance in Practice (How am I doing?)
   Physicians must 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.

The FSMB has also adopted five important principles to guide the work of MOL:

• MOL should support physicians’ commitment to lifelong learning and facilitate improvement in physician practice.
• MOL systems should be administratively feasible and should be developed in collaboration with other stakeholders. The authority for establishing MOL requirements should remain within the purview of state medical and osteopathic boards.
• MOL should not compromise patient care or create barriers to physician practice.
• The infrastructure to support physician compliance with MOL requirements must be flexible and offer a choice of options for meeting requirements.
• MOL processes should balance transparency with privacy protections.

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State medical and osteopathic boards and the medical profession as a whole are facing increasing demand for greater accountability and transparency. Some of the factors prompting the MOL initiative include:

• This is part of a larger movement to improve quality and patient safety.
• Increasing public demands that the quality of care delivered by our health care delivery system continuously improve.
• Research that suggests physicians may develop deficits in important skills and knowledge the further away they get from medical school and residency training.

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The ultimate goal of any MOL program is to improve patient care. To achieve that goal, MOL programs would need to support continuous learning as a touchstone of physicians' lifelong practice.

The intent of MOL is to promote quality improvement and continuous professional development for licensed physicians. It is not designed with the intent to identify and remove "bad" doctors from practice. MOL should encourage lifelong learning and be a verifiable system of individual practice improvement efforts.

By implementing a MOL process, state boards would serve as the foundation for a "culture of improvement" encompassing the entire medical regulatory system.

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The first component of MOL, reflective self-assessment, relates to physicians' professional obligation to commit to lifelong learning to maintain their skills and to learn new and updated knowledge affecting their practice. Component One is designed to be the physicians' self-directed, but objectively verifiable, learning activity. Building on physicians' long-standing professional commitment, Component One begins with the established Continuing Medical Education (CME), whereby physicians would complete certified and/or accredited CME, a majority of which is practice-relevant and supports performance improvement. State licensing boards may need to evaluate and enhance, where appropriate, existing CME requirements for licensure renewal.

The second MOL component relies on objective or external knowledge and skills assessments to produce data to identify learning opportunities and guide improvement efforts. Many types of external assessments are structured, valid and practice-relevant and can provide valuable individual and comparative data for physicians to evaluate and maintain their skills and knowledge. State boards may want to concentrate their efforts on requesting licensees to document use of tools from objective third parties with demonstrated expertise in these activities to assess their own knowledge and skills.

For the third component, performance in practice, physicians should use data derived from their own practices, perhaps supplemented by practice improvement activities already being implemented by specialty societies, hospitals, physician groups and quality improvement organizations, to evaluate outcome variation both internally within their own practices as well as externally compared to their local and national peers when such data is available. Such information would be used to align their clinical practices with national recommendations. Component Three qualifying activities could include a variety of methods that incorporate reference data to assess physician performance in practice as a guide to improvement. As health information technology advances, component three is most likely to evolve over time.

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The Federation of State Medical Boards develops model policies at the requests of its members; it does not have the authority to license and regulate physicians. That authority rests with the individual states and U.S. territories, which carry out this responsibility through their medical licensing boards. There are 69 such boards: some boards license allopaths (physicians holding M.D. degrees); some, osteopaths (physicians holding D.O. degrees); and some, both. All belong to FSMB.

The states and territories are free to adapt model policies to meet their jurisdictional needs. In sum, a model policy is just that - a model - unless and until a state or territory translates it into statute or regulations.

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All 24 medical and surgical specialty boards that belong to the American Board of Medical Specialties are in the process of implementing programs that require physicians to demonstrate continuing competence in order to maintain their board certification in a specific specialty. The American Osteopathic Association-Bureau of Osteopathic Specialists has directed that its member boards implement continuous certification requirements by January 1, 2013.

The Joint Commission, which is the accreditation body for U.S. health care organizations and programs, has enacted new standards that include quality improvement activities and performance-monitoring for physicians among its requirements for granting hospital privileges. The Accreditation Council for Continuing Medical Education, the Accreditation Council for Graduate Medical Education, and the American Medical Association are other organizations that have placed continuous learning and practice improvement at the center of their principles for lifelong practice.

Licensing boards and FSMB are working in collaboration with these organizations as MOL moves forward to implementation. However, as the FSMB's 2004 policy directive makes clear, state boards also believe they have a unique role in ensuring the ongoing competence of licensed physicians. As the sole entities that regulate all physicians and that operate with a direct mandate to protect the public's safety, the U.S. medical licensing boards have a unique responsibility to assure physicians' ongoing competence and continuous improvement.

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The vast majority of physicians are already pursuing continuing medical education and training to keep their knowledge and skills current, and many do so through the maintenance of certification programs required by their specialty boards or other quality improvement activities. State medical and osteopathic boards at their discretion may determine that participation in these activities represents substantial compliance with MOL requirements. For those physicians who are not specialty board certified, not participating in a process of ongoing specialty board certification, or engaged in non-clinical roles, a number of options have been recommended by the FSMB's MOL advisory group and implementation group to help them demonstrate their adherence to lifelong learning in their area of practice.

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Patients today benefit from the availability of services from physicians who may not be present in their state when the services are provided but who are licensed in their state, as is often the case with telemedicine. State medical and osteopathic boards realize that policies they impose must not interfere with physicians' ability to secure licensure in other states. Consistency will be necessary among states when adopting MOL requirements to avoid interstate mobility and practice issues. One of the principles adopted by the FSMB to guide the MOL initiative states, "Maintenance of Licensure should not compromise patient care or create barriers to physician practice."

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