India is keen to align to the general international standards laid down for continuing medical education (CME)/continuing professional development (CPD) practices by the World Federation for Medical Education (WFME).(1) The Medical Council of India (MCI) has been facilitating CME programmes in India since 1985.(2) In 1997, the MCI recommended to the Central Government to make attendance in CME programmes mandatory, with renewal to be done every 5 years.(3) In this article, an overview is presented of the current uptake of CME practices across different state medical councils.
We carried out an analysis of the public websites of all the 30 state medical councils in India available on line in April 2020. Of the 30 state medical councils, only 24 manage a website. On the public part of the website, 21 state medical councils provided information on CME. Fourteen medical councils stated the credits required for renewal (Table 1).
|State Medical Council||Required credits||Online CME|
|Arunachal Pradesh (5)||30||Yes|
|Delhi (7)||Not mentioned||Yes|
|Haryana (10)||Not mentioned||No|
|Himachal Pradesh (11)||Not mentioned||Yes|
|Madhya Pradesh (14)||30||Yes|
|Nagaland (17)||Not mentioned||No|
|Orissa (18)||Not mentioned||Yes|
|Tamil Nadu (20)||Not mentioned||Yes|
|Tripura (21)||Not mentioned||Not mentioned|
|Uttar Pradesh (22)||30||Yes|
|West Bengal (24)||30||No|
Twelve medical councils demanded 30 CME credits in 5 years. While attending live events, one credit was usually awarded for 2 hours of study. Fifteen state medical councils accepted the accreditation of online CME modules. Seven of those medical councils accepted international accreditation on the basis of 1 credit for 1 hour of study.
Giving some specific examples, the Karnataka Medical Council (KMC) demands 30 CME credits within a re-registration period of 5 years, but they have an additional stipulation that a practitioner can obtain only 6 CME credits per year. They allocate only one credit for 4 hours of CME study, raising the bar in practice to the equivalent of 120 CME credits on a 1-hour to 1-credit basis. In comparison, in the UK, 250 CME credits are required every 5 years. Therefore, the demand on Indian medical practitioners falls short by 52% as compared to that on doctors in the UK. Only the Gujarat Medical Council has raised its bar for re-registration above the practices in developed countries, with a demand of 150 CME credits, while allocating only 1 credit to 2 hours of CME study. This would mean a real-time investment of 300 hours of study for every re-registration period of 5 years.
The Indian Medical Council Act, 1956 provides for lifetime registration of medical doctors. In view of the same, some members of the medical fraternity felt that unacceptable that a medical qualification should have a validity of 5 years only. These ‘renewal skeptics’ argued that as long as the Central Government did not introduce any amendment to the Medical Council Act in Parliament, the provisions as enshrined in the Act would be prevalent.3 The KMC was challenged in 2016 on the lawfulness of the renewal practice. They referred to a MCI letter (No. MCI-311(4)/(Gen)/2009-CME/31504, dated 24 August 2009), which states that as per the current provisions of the Indian Medical Council Act, 1956, once registration is granted to a doctor and consequential entry made in the Indian Medical Register in accordance with Sections 15, 21, 23 and 27, it is permanent for one’s lifetime and does not require either attendance in CME programmes or periodical renewal of registration.
The MCI had recommended to the Central Government way back in 1997 to make attendance in CME programmes and renewal of registration every 5 years mandatory, and to suitably amend the Indian Medical Council Act, 1956.
In December 2016, an interim order was issued to the KMC by the Karnataka High Court directing the State Council not to cancel licenses of Indian Medical Association (Karnataka Chapter) members as well as other doctors who failed to submit renewal applications as well as the renewal fee by 31 December 2016.(25).
In Karnataka, 2458 respondents signed a petition to stop the practice of renewal.(26) However, in a survey conducted in 2018 on the website of the KMC among their members to examine their interest in online CME, 4999 members were in favour of the same.(27) However, Dr H. Veerabhadrappa, Council President remained firm in his ambition to update its registry. The KMC had no intention of relaxing any rules, but allowed more time for its members to align to their requirements.(28)
The CME requirements by state medical councils do not describe terms for conditional re-registration in case a physician fails to comply with the general framework. This may increase anxieties at the time of implementation of such requirements.
Recent attempts have been made to update the registers of health-care practitioners in India. Thanks to the progress of Aadhar (which is a 12-digit random number issued by the Unique Identification Authority of India [UIADI] to residents in India as part of the largest biometrics-based identification system in the world), professional bodies can improve the quality of their registries by demanding that health-care professionals provide their Aadhar number at the time of re-registration.(29) As of July 2017, over a million doctors had already registered their Aadhar numbers with the MCI.(30)
The Arunachal Pradesh Medical Council (APMC) intimated that implementation of a CME requirement in the State was problematic, as many doctors were continuing to practice in the State without registration. In addition, nursing homes and clinics attracted doctors from other states to work at their premises without informing the APMC.(31)
The MCI does not allow dual registration with two separate state medical councils. Though a doctor registered with a state medical council is deemed to be on the rolls of the Indian Medical Register maintained by the MCI, existing rules bar a doctor registered with one state medical council from practising within the jurisdiction of another state medical council without first obtaining a no-objection certificate, followed by re-registration.(32)
In 2017, MCI has directed all states to provide a unique permanent registration number (UPRN) to every doctor registered in their jurisdiction.(33) This initiative will put an end to the duplication of doctors’ names being registered with various state medical councils as well as the Indian Medical Register under the MCI, and provide a clear picture of how many doctors are practicing in India. A UPRN number is to be generated for the over 1 million doctors recorded in the IMR. A UPRN number will also assist state medical councils greatly in the implementation of CME practice.
A survey conducted by Manan D. Shah et al.(34) among predominantly male Indian specialist physicians with regard to the preferences and attitudes of physicians in India towards CME demonstrated that the majority preferred live, short, interactive CME activities which were speciality-specific, focused and digitally enabled. Ideally, these sessions should be organized by medical associations and delivered by Indian experts.
At the First Regional Meeting of the Global Alliance for Medical Education (GAME) in Mumbai on 18 October 2014, Dr Rajesh Upadhyay, President Elect of the Association of Physicians of India stated that the uptake of CME activities by physicians and nurses was still limited, as it was not yet mandatory.(35)
The demand to make CME mandatory in India calls for a critical balancing act, as India faces an acute shortage of over 64 lakh (6.4 million) skilled human resources in the health sector. Against a global average of 14.2, the physician density of India per 10,000 population stands poorly at 6.5.(36) It was calculated that each demand to gain one CME credit by means of a live event meant a loss of approximately 6.85 million clinical hours for the 1.0 million physicians (Table 2).
|Number of Indian physicians (as on 31 December 2016 as per Medical Council of India records)||10,12,428, i.e. approx. (~1.0 million)|
|Study time required to earn 1 credit through a live event*||4 hours|
|Average travel time to CME venue**||2.85 hours|
|Time required per doctor to earn 1 CME credit||6.85 hours|
|Time required for all registered doctors to earn 1 CME credit with live event||[6.85 x 1.0 million] = 6.85 million hours|
As per Medical MCI guidelines,(37) attendance of 4 hrs of conference entitles a doctor to 1 CME credit.
** Travel time of 2.85 hours per credit is arrived at by calculation of a weighted average of rural and urban doctors, considering a minimum of travel time of 12 hours per day for rural doctors and 3 hours per day for urban doctors. Urban to rural distribution is taken as approximately 30:70.
Dr R. Doye, Director of Medical Education, APMC expressed his concern with regard to this loss of clinical time. He objected to making 30 credits mandatory, as only doctors in or in the periphery of Itanagar, the capital of Arunachal Pradesh, would be able to attend live events. Dr. Moji suggested conducting CME at the district level in future.(38) The KMC tried to resolve the issue of travel time by dividing its state into 28 zonal districts, and having live events at district level.(39) However, travel time to an event is estimated to lead to a yearly loss of 17 million clinical hours (Table 3). An introduction of 100% online CME would save one whole working week (35.1 hours) per year per physician.
|Participant time or clinical time spent (hours)||Study time||Travel time||Total time|
|Per doctor to earn 1 CME credit hour||4||2.85||6.85|
|Per doctor per year (time required for 1 credit x 6)||24||17.1||41.10|
|Per doctor in 5 years (time required for 1 credit x 30)||120||85.5||205.50|
|Participant time or clinical time spent (hours)||Study time||Travel time||Total time|
|Per doctor to earn 1 CME credit hour||1||0||1|
|Per doctor per year (time required for 1 credit x 6)||6||0||6|
|Per doctor in 5 years (time required for 1 credit x 30)||30||0||30|
Each physician thus loses as much as 35.10 hours if he has to earn his 6 annual credits through live events as opposed to on line CME. For the total workforce of 1 million doctors, this means a staggering loss to the nation of 35.10 x 1 million = 35.10 million clinical hours. Clearly, the way forward is to adopt on line CME for all states in the country.
Organizing and supervising CME activities is a herculean task for state medical councils. The procedure requires physical approval of every application for every live event. In addition, they send one or two observers to each live event to ensure attendance by registered doctors. In India, a minimum number of 3 million conference days of CME events are required per year. If an attendance of 100 delegates is estimated, it would require 60,000 observation days per year (Table 4), excluding travel time.
|Study days to earn credit (4 hours = 0.5 days)||0.5|
|Study days to earn 6 credits (0.5 x 6)||3|
|Study days to be organized for all physicians (1.0 million) to earn 6 credits (number of physicians x 3)||3 Million|
|Observers per conference day considering 100 participants||2|
|Observation days (study days for all physicians x 2)/100)||60,000|
A move towards online CME is thus inevitable to ensure that all physicians get adequate access to CME. In India, the National Knowledge Network(40) is working since 2016 on the online education backbone interlinking as many 150 medical colleges to create a common learning platform. This has been deployed by Central and state government agencies. This brings high speed optic fibre-based Internet within reach of many health-care students and professionals. The National Knowledge Network acknowledges that good faculty is critical, but difficult to find. Therefore, accredited online educational modules can increase the action radius of medical trainers.
As long as the re-registration process remains manual, the administrative burden on overstretched health-care professionals will increase. This may in turn increase their resistance to comply with the re-registration process. Currently, state medical councils are registering all the attendance certificates. It requires automation to make the task feasible. The Maharashtra Medical Council offers paperless certification, but charges INR 10 per certificate.(41) These charges may have assisted them to automate their CME process. This approach seems to have paid off, as their website as on 17 April 2020 compiles an overview of more than 354 fully accredited CME organizations, 96 organizations with partial accreditation and 107 organizations for case-to-case accreditation. They have accredited more than 8442 general speakers and 10 speciality speakers.(42) Most state medical councils offer the facility to upload attendance at CME events free of cost. The West Bengal Medical Council charges INR 100 per delegate to generate a certificate.(24)
Further automation of registration is required to proceed in a standardized manner. Ideally, practitioners should be able to maintain their registration easily, and state medical councils should be able to track them effortlessly. The way has already been paved for medical practitioners to register with several state medical councils simultaneously. This can optimize the use of a scarce and highly trained workforce.
Online CME modules are gradually becoming available for Indian health professionals. A total of 15 state medical councils accept online CME (see Table 1). In 2011, www.mycme.com was launched for Indian health-care professionals at a Royal College of General Practitioners (RCGP) meeting in Delhi.(43) BMJ learning has a collaboration with the Delhi Medical Council and Karnataka Medical Council to accept the credits that their doctors acquire through online CME.(44),(45) The Gujarat Medical Council accepts credits from IMA e-varsity(46). This is an initiative by the Indian Medical Association, College of General Practitioners. Their CME programme was initially approved by the Tamil Nadu Medical Council. The Maharashtra Medical Council accepts online education too, but only for 20% of the total credits for practitioners residing in Maharashtra, while those living outside their state get the benefit for 100% of total credits.
There is an Indian edition of ‘GP Clinics’,(47) a journal that caters specifically to the CME needs of general practitioners and MD physicians. In 2016, the National Academy of Medical Sciences, India, re-initiated the publication of its CME monographs on its website.(48)
As of now, live events are still the most popular way in which CME is conducted. The Indian Medical Association, with more than 1700 branches, organizes monthly classroom CME meetings with local speakers, sponsored by pharma companies.(49) The Association of Physicians of India is also a player on the CME field with its yearly APICON congress and its journal.(50)
The Indian Medical Council has a running long-term programme to provide financial assistance of up to a maximum of INR 1.00 lakh (0.1 million) to the institutions hosting live CME programmes with participation of NRI faculty from USA/UK/Canada. This money is to meet the expenses of the visiting NRI faculty including foreign faculty, if any, and for publication of programme proceedings. They host 100 to 150 such programmes a year.(2)
In 2014, Venkataraman R et al.(51) demonstrated that self-sponsoring candidates preferred activities with international accreditation.
In 2019, Omnicuris was launched, an Indian online CME platform. Accreditation of their certificates may be awarded retrospectively by State Medical Councils, not by an independent accrediting body.(52)
Ideally, online CME modules with international accreditation should be made available to Indian health-care professionals, keeping in mind affordability and transparency with regard to ties to industry.
At the second Indian GAME conference in 2016, the attendees recommended a uniform accreditation policy across India. They were in favour of establishing an interstate body for CME accreditation. This body should issue guidelines for selection criteria for CME providers for their CME/CPD systems. This should lead to the recognition of competent Indian CME providers. There is a need for a facilitator to meet the criteria set by the central governing body. A clear distinction should be made between independent, company-driven, company-initiated and collaborative medical education. CME should be delivered in any available mode (live, online, print). Internationally accredited CME should be recognized in India as well. Every CME activity should be accompanied by a declaration of interest.(53)
Online CME is gaining momentum in India. Till date, 15 out of 30 state medical councils accept online CME education. The MCI had recommended making CME and re-registration mandatory in 2007. Implementation of CME and re-registration are hampered by incomplete registries of practitioners. The generation of a UPRN for every practitioner is expected to streamline this matter. Although many health-care professionals prefer live, interactive CME activities, these are impractical in terms of time management; and besides, are out of reach for many rural practitioners. Automation of the re-registration process is essential to ensure the feasibility of this task for state medical councils. There is a gradual increase of available online CME modules in India, but affordability as well as transparency with regard to ties to industry need to be ensured.
Emma Van Hoecke is the founder of CMEPEDIA. She has not received any funding.
A draft of this article is submitted to the National Medical Journal of India for publication.