CME Licensing

For more than 30 years, physicians who participate in continuing medical education (CME) have been recognized by the American Medical Association (AMA) with the Physician's Recognition Award (PRA). Moreover, the PRA category 1 credit system established by the AMA has become the CME standard for licensing boards and specialty organizations nationwide.

A physician's patients and colleagues recognize the certificate as evidence of a commitment to keeping up to date with advances in biomedical science and other developments in medicine. The PRA certificate is valuable to physicians because many organizations accept it as evidence of participation in CME. Some states' licensing boards and hospitals will accept the PRA as proof of having completed the required CME. A PRA application from a physician working in a hospital that has been stamped "Approved" by the AMA will be accepted for review by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) in connection with the hospital's accreditation process.

After completing his or her undergraduate, medical school, and graduate medical education, a physician must still obtain a license to practice medicine from a state or jurisdiction of the United States in which he or she is planning to practice. Physicians apply for the permanent license after completing a series of exams and completing a minimum number of years of graduate medical education.

The majority of physicians also choose to become board certified, which is an optional, voluntary process. Certification ensures that the doctor has been tested to assess his or her knowledge, skills, and experience in a specialty and is deemed qualified to provide quality patient care in that specialty. There are 2 levels of certification through 24 specialty medical boards -- doctors can be certified in 36 general medical specialties and in an additional 88 subspecialty fields. Most certifications must be renewed after 6 to 10 years, depending on the specialty.

Learning does not end when physicians complete their residency or fellowship training. Doctors continue to receive credits for continuing medical education, and some states require a certain number of CME credits per year to ensure the doctor's knowledge and skills remain current. CME requirements vary by state, by professional organization, and by hospital medical staff organization.

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  • The approved PRA application is accepted by JCAHO as evidence of completing CME requirements.
  • The PRA certificate simplifies the relicensure process because 17 state licensing boards recognize the PRA certificate as proof of completion of CME requirements.
  • American Board of Medical Specialties board certification or recertification earns physicians a 3-year PRA.
  • A PRA certificate demonstrates to patients and colleagues a physician's commitment to continuous development.
  • Documentation of the PRA is included in the AMA Masterfile, indicating to patients and healthcare organizations that a physician has kept up with medical advances.

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CME consists of educational activities that serve to maintain, develop, or increase the knowledge, skills, and professional performance and relationships a physician uses to provide services for patients, the public, or the profession. The content of CME is that 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 healthcare to the public.

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CME should be chosen for its educational value and not for amenities unrelated to the educational purpose of the activity. Participation in activities where industry has paid any of the physician's expenses or offered any other inappropriate gift is unethical and those activities may not be claimed for credit.

Physicians should claim credits commensurate with the actual time spent on an activity. The award recognizes physicians truly dedicated to providing their patients with the most up-to-date and appropriate medical care.

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Physicians may apply for the PRA if they hold a valid and current license issued by one of the US, Canadian, or Mexican licensing jurisdictions or are engaged in residency training in an accredited program in the United States or Canada. International members of the AMA are also eligible for the award.

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Category 1 activities are those that are formally planned and adhere to Accreditation Council for Continuing Medical Education (ACCME) Essential Areas and Policies. The following activities may be designated for AMA PRA category 1 credit.

Attendance-based activities
CME activities that require the physician to be in attendance to receive credit include workshops, seminars, grand rounds, and departmental scientific meetings.

New procedures
New procedures and skills courses allow physicians to request new or expanded clinical privileges. Therefore, it is necessary that a physician's knowledge and skills to carry out the new procedure be assessed. The AMA has established a system of 4 levels that reflect the education and training a physician has achieved in the new procedure. After completing an educational activity, the physician may then present this certificate to the appropriate credentialing authority as documentation of his or her education and training.

The 4 levels are:

  1. Verification of attendance
    The physician attended and completed the course.
  2. Verification of satisfactory completion of course objectives
    The physician satisfactorily met all specified learning objectives.
  3. Verification of proctor readiness
    The physician is "proctor ready," which includes levels 1 and 2, and the physician is able to perform the procedure under proctor supervision.
  4. Verification of physician competence to perform the procedure
    The physician is competent to perform the procedure without further supervision.

Enduring materials
Enduring materials are printed, recorded, audio, video, or electronic activities, including Internet, computer-assisted instruction, and broadcast activities. To be designated for AMA PRA category 1 credit, enduring materials must:

  1. Comply with the standards for category 1 activities.
  2. Provide clearly stated instructions to the learner and be established for a predetermined amount of time required to complete the activity.
  3. Provide access to supplemental materials to reinforce and clarify specific information.
  4. Include some type of student interaction, such as considering a patient-management problem or answering questions. Often, this is done in the form of an examination of the physician's knowledge acquisition and ability to apply the new material in a simulated problem. Examinations should be scored confidentially and returned to the physician along with his or her credit certificate.
  5. Have a means of verifying physician participation. This might be the examination or an evaluation of the activity. It should include a place for physicians to record the actual time spent on the activity, up to the maximum number of credit hours that may be earned. Credit may be awarded to physicians who submit materials verifying participation in the activity. Any certificate should award credit hours based on the physician's statement about time spent on the activity.
  6. Provide a local instructor when category 1 enduring materials are used by groups of physicians. The instructor is expected to lead the discussion. Physicians who serve as instructors may claim credit hours for a category 1 teaching activity.

Journal-based CME
Journal activities may be designated by an accredited provider for AMA PRA category 1 credit, provided:

  1. The activity meets the criteria for formal CME activities. This means the learning objectives and target audience must be clearly identified and the activity must be appropriate in depth and scope. There must be some means of determining physician participation and activity compliance with its stated objectives, such as an evaluation or examination to be returned to the provider for credit.
  2. The material appears in a peer-reviewed journal, ie, one that is included in the Index Medicus.
  3. The accredited provider develops an overall educational plan that will be covered over a defined period of time, including an appropriate evaluation at the end of the period. The topics selected should be designed to meet the needs of the journal's readers.
Providers determine the maximum number of credit hours for an activity by a good-faith estimate of the number of hours dedicated to education in the planned activity. Physicians should be instructed to claim only the actual time spent on the activity. The time it takes to participate in an activity should be rounded to the nearest quarter hour and credit hours should be awarded accordingly. In most cases, journal-based CME is not designated for more than one credit hour.

If an activity contains sections that do not meet the definition of CME or are not at a level appropriate to physicians, these sections should be clearly identified and excluded from the designation of category 1 credit.

Some category 1 activities physicians may earn credit for are not designated by providers. Credit for these activities must be applied for from the AMA PRA department. Such activities include:
  • Articles physicians publish in peer-reviewed journals;
  • Poster presentations and teaching at conferences approved for category 1 credit;
  • Specialty board certification and recertification;
  • Medically related degrees; and
  • Participation in an Accreditation Council for Graduate Medical Education (ACGME)–accredited program.

Physicians may also earn category 1 credit for attending international conferences approved for AMA PRA category 1 credit and undertaking an independent learning program preapproved by the AMA.

The PRA program evolves to meet the learning needs of physicians. Therefore, the AMA will, from time to time, initiate pilot programs and projects to evaluate and eventually recommend new ways for physicians to earn category 1 credit.

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Category 2 credits are awarded for activities not designated for category 1 credit that a physician feels have had educational value. These activities include attending a workshop not designated for category 1 credit, studying online, and reading authoritative medical literature. Category 2 activities are less structured educational activities that meet the AMA Definition of CME, comply with the AMA’s Opinion on Gifts to Physicians, meet commercial support policies, but otherwise don’t fully meet the Essential Areas and Policies. This is usually in the area of Essential Area 2 (planning). See the AMA Reference Pages in the CME Policy and Procedures Manual for more detailed information on category 2 credit. Physicians may claim category 2 activities on the PRA application form.

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Fifty-one boards require anywhere from 12 hours (Alabama) to 50 hours (several states) of CME per year for licensure re-registration. Some states also mandate CME content, such as HIV/AIDS, risk management, or medical ethics. In addition, many states also require that a certain percentage of CME be category 1, as measured, eg, through the AMA PRA. Details by State are available from the AMA: Continuing Medical Education for Licensure Re-registration.

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