Maintenance of licensure moving forward

For many years, the Federation of State Medical Boards (FSMB) has been actively pursuing the development of a maintenance of licensure (MOL) program. Numerous committee and stakeholder meetings have centered on the concept and how the state medical boards can take it from the theoretical to the implementation level. Because licensure is critical to surgical practice, it is important that surgeons have some understanding of how changes in licensing are likely to affect them in the coming years, or at least what they may have to do to maintain licensure.

Many physicians may not yet know what MOL is or why it is necessary, as they may have heard or read only generalities about the topic. With that in mind, this article presents a more in-depth overview of MOL.

Describing MOL

Simply stated, MOL is a process by which licensed physicians periodically provide, as a condition of license renewal, evidence that they are actively participating in a program of continuous professional development. This activity should be relevant to areas of practice, measured against objective data sources, and aimed at improving performance over time.*

According to the FSMB, the rationale for developing and implementing a MOL system is an outgrowth of the health care system’s evolving emphasis on improving patient safety and quality outcomes. Continuous quality improvement has become a staple of policymakers, especially with the adoption of health system reform. In addition, state medical boards have long recognized their responsibility to protect the public and promote quality health care by ensuring that only qualified individuals receive a license to practice medicine and deliver health care.

Status of MOL

In 2010, the FSMB House of Delegates adopted a framework for MOL. Under this paradigm, physicians would periodically provide evidence of participation in professional development and lifelong learning activities based on the general competencies model: medical knowledge, patient care, interpersonal and communication skills, practice-based learning and improvement, professionalism, and systems-based practice.

Three major components of effective lifelong learning are included in this framework:

  • Reflective self-assessment through which physicians participate in an ongoing process of self-evaluation and practice assessment with subsequent successful completion of tailored educational or improvement activities
  • Assessment of knowledge and skills, which calls for physicians to demonstrate the knowledge, skills, and abilities necessary to provide safe, effective patient care within the framework of the general competencies as they apply to their individual practice
  • Performance in practice, meaning physicians should demonstrate accountability for their performance using a variety of methods that incorporate reference data to evaluate their practices and guide improvement*

The FSMB adopted five guiding principles to further assist in the development of MOL. Based on these guidelines, MOL should do the following:

  • Support physicians’ commitment to lifelong learning and facilitate improvement in physician practice.
  • Demonstrate administrative feasibility and should be developed in collaboration with other stakeholders. The authority for establishing MOL requirements should remain within the purview of state medical boards.
  • Avoid compromising patient care or creating barriers to physician practice.
  • Offer flexible support for physician compliance with MOL requirements and provide options for meeting requirements.
  • Balance transparency with privacy protections.

Every time a new program or process affecting physicians is discussed, legitimate concerns are expressed regarding compliance, such as whether the new system will create additional practice burdens, and so on. To address some of these concerns, the FSMB came up with a list of explanatory comments to reassure physicians that MOL is not intended to impose an additional level of regulatory bureaucracy, which includes the following:

MOL is being constructed in a way that is carefully integrated and coordinated with activities of other organizations. The FSMB is working closely with the American Board of Medical Specialties, which administers the Maintenance of Certification (MOC) program for physicians; however, MOC will not be required as a part of the future MOL system. Similarly, Osteopathic Continuous Certification (OCC) will not be required for MOL. The three systems are independent. The FSMB is recommending, however, that physicians engaged in MOC or OCC be recognized as being in “substantial compliance” with the three MOL components: reflective self-assessment, assessment of knowledge and skills, and performance in practice.

MOL is being constructed in a way that minimizes additional burdens for physicians. It will not mandate a high-stakes examination as a part of its structure. For physicians who are not board-certified in a medical or surgical specialty and, therefore, not engaged in MOC or OCC, the FSMB will help identify activities that could satisfy MOL.

MOL is being constructed in a way that takes into account the wide variation in clinical activity among physicians. Licensed physicians in the U.S. include professors, executives of health care organizations, policymakers, and other individuals who are part of a broad spectrum of professional niches. In recognition of the diversity in physicians’ professional endeavors, the FSMB is working with health care organizations to create a system that fairly evaluates and assesses the activities of all licensed physicians. Many kinds of professional activities outside of clinical practice may be acceptable for MOL and are being evaluated.

These assurances are very important to physicians. One early critique of MOL was that it would result in a significant increase in regulatory burdens, especially for physicians already working hard to keep up with MOC requirements. Ultimately, it will come down to how state medical boards choose to implement MOL, and at this stage of the process, it seems these boards have little interest in further complicating the licensure process by imposing additional burdens on licensees or on themselves.

Going forward

It will be a while before an MOL system is implemented. The FSMB is currently working with a few state medical boards on MOL pilot projects, and the results will be critical in determining how to roll out the program. One suggestion calls for MOL to be implemented in phases based on the major components of lifelong learning as previously described, starting with reflective self-assessment, then adding assessment of knowledge and skills, and finally including performance in practice, which may be the most difficult of the three to demonstrate and evaluate.

In the meantime, the FSMB has posted a useful MOL resource Web page. The site provides fact sheets, federation reports, and other items and will provide updates over time on MOL implementation.

Of particular interest to surgeons may be FSMB Board Report 11-3: Report of the MOL Implementation Group. In Attachment B of the report is a suggested toolbox for implementation of MOL along with a description of the professional development programs and activities for the three major components of lifelong learning, such as continuing medical education, participation in registries, use of self-assessment tools, and so on. With access to these resources, along with the FSMB’s sensitivity to realistic development of MOL requirements and processes, implementation should have limited impact on the practicing surgeon.


*Federation of State Medical Board. Maintenance of licensure: Frequently asked questions. Available at: www.fsmb.org/m_mol_faqs.html. Accessed April 26, 2013.
Chaudhry H, Cain F, Stax M, Talmage L, Rhyne J, and Thomas J. The evidence and rationale for maintenance of licensure. J Med Reg. Available at: www.fsmb.org/pdf/mol-evidence-article.pdf. Accessed May 6, 2013.
Federation of State Medical Board. Maintenance of licensure: A special report. Available at: www.fsmb.org/pdf/mol-new-vision.pdf. Accessed April 26, 2013.

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