Medical licensure is a practice requirement in all states and territories in the United States and the District of Columbia. Licenses are issued by state medical boards, with some states having separate licensing boards for doctors of osteopathy.

Established in 1912, the Federation of State Medical Boards (FSMB) represents all of the nation’s state medical and osteopathic boards and functions as a clearing house of information about common licensing issues and professionalism. Recently, the FSMB turned its attention to protecting the public from physicians and surgeons of poor quality or competence.

The MOL initiative
Part of the increased attention to physician competence is due to the initiative to create a Maintenance of Licensure (MOL) program, similar to the Maintenance of Certification (MOC) process now in place for all medical specialty boards, including the American Board of Orthopaedic Surgery (ABOS). Unlike board certification, however, renewal of a medical license is required for orthopaedists to continue to practice orthopaedic surgery.

In 2010, the FSMB adopted MOL as a process with the following three parts:

1. Reflective self assessment (What improvements can I make?)
2. Assessment of knowledge and skill (What do I need to know and be able to do?)
3. Performance in practice (How am I doing?)

The FSMB also created an implementation task force to help all state medical boards implement the MOL process between the years 2015 and 2020. It’s important to note that the wording of the 2010 agreement states that “participation in MOC…represents substantial compliance with maintenance of licensure requirements.”

The FSMB set up pilot programs in 11 states to begin later this year. In nine states (Colorado, Delaware, Iowa, Massachusetts, Mississippi, Ohio, Oregon, Virginia, and Wisconsin) and in the District of Columbia, the medical board will operate the pilot program. In California and Oklahoma, the osteopathic licensing board will operate the pilot program.

Although the exact format of each pilot program will be decided by the individual state medical or osteopathic boards, common elements will include practice assessment, effective patient care, and accountability for performance in practice. It is likely that patient surveys, evidence of performance-improvement, continuing medical education, and evidence of participation in a quality assessment/improvement process will be required.

In addition, orthopaedic surgeons with time-unlimited (lifetime) certification will be asked if they have taken a secure knowledge exam (board recertification exam) within the past 10 years. MOL is likely to replace the current simple license renewal process in all states and territories and there is no evidence yet that those who are not participating in specialty-board sponsored MOC programs will be ‘grandfathered.’

It is highly likely that practicing surgeons who are not certified, including those with time-limited certificates that expire after 10 years, will be required to take some type of medical exam to keep their medical licenses. It is also possible that time-unlimited diplomates of the ABOS may be asked to take a state medical license exam if they do not recertify via the ABOS-approved MOC program.

The impact on orthopaedics
Orthopaedists who practice in one of the states that will pilot the MOL process should contact the state medical board to learn about any MOL requirements. Eventually, all state medical boards will have an MOL process rather than license renewal; in the meantime, it is very important that orthopaedic surgeons know the rules of MOL in their state and plan accordingly.

The American Board of Medical Specialties, of which the ABOS is a member, has asked that participation in the MOC of specialty boards (ABOS for orthopaedic surgeons) serve as meeting the requirements of MOL. For now, the ABOS has been assured that those diplomates who are currently certified and participating in the MOC process (including time-unlimited diplomates) will be deemed to have met the MOL requirements and will be granted licensure renewal. This means that an orthopaedic surgeon with a lifetime certificate or lapsed certification may enroll in MOC without having to recertify to maintain their medical license.

The final form of MOL is not yet known, but the FSMB has agreed to make MOL happen within the next few years. Practicing orthopaedists need to be aware that changes in medical licensure at the state level are coming and that participation in MOC will be helpful in responding to those changes.

Shepard R. Hurwitz, MD, is executive director of the ABOS. He can be reached at shurwitz@abos.org