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The gradual development of online CME practice in India

Introduction

India is keen to align with 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 done every five years. 3 This article presents an overview of the current uptake of CME practices across different state medical councils.

Methodology

We analyzed the public websites of all the 29 state medical councils in India available online in February 2023. All state medical councils manage a website. On the public part of the Website, 20 state medical councils provided information on CME. Fifteen medical councils stated the credits required for renewal (Table 1).

Table 1: Credits required for renewal by state medical councils

  State Medical Council Required credits Online CME
1 Andhra Pradesh 4 30 Yes

2

Arunachal Pradesh 5

 30 Yes
3 Assam 6 No website No website
4 Bihar7 Error 404 Error 404
5 Chattisgarh 8 30 Yes
6 Delhi 9 Not mentioned Yes
7 Goa 10 30 Yes
8 Gujarat 11 150 Yes
9 Haryana 12 20 No
10 Himachal Pradesh 13 Not mentioned Yes
11 Jammu and Kashmir14 Not mentioned Not mentioned
12 Jharkhand 15 Not mentioned Not mentioned
13 Karnataka 16 30 Yes
14 Kerala 17 30 No
15 Madhya Pradesh 18 30 Yes
16 Maharashtra 19 30 Yes
17 Manipur 20 30 Yes
18 Mizoram21  Not mentioned Not mentioned
19 Nagaland 22 Not mentioned No
20 Odisha 23 Not mentioned Yes
21 Punjab 24 50 Yes
22 Rajasthan25 30 Yes
23 Sikkim26 Not mentioned Not mentioned
24 Tamil Nadu 27 30 Yes
25 Telangana Not mentioned Not mentioned
26 Tripura 28 Not mentioned Not mentioned
27 Uttar Pradesh 29 30 Yes
28 Uttarakhand 30 30 Yes
29 West Bengal 31 30 No

Fourteen medical councils demanded 30 CME credits in 5 years. While attending live events, one credit was usually awarded for 2 hours of study. Seventeen 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. Still, 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, 250 CME credits are required every five years in the UK. Therefore, the demand for Indian medical practitioners falls short by 52% compared to 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 one 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.

Discussion

Legal basis

The Indian Medical Council Act of 1956 provides for the lifetime registration of medical doctors. Given 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 sceptics’ argued that as long as the Central Government did not introduce any amendment to the Medical Council Act in Parliament, the provisions enshrined in the Act would be prevalent. The KMC was challenged in 2016 on the lawfulness of the renewal practice. They referred to an 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 by 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 five years mandatory and to amend the Indian Medical Council Act of 1956 suitably.

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. 32 .

In Karnataka, 2458 respondents signed a petition to stop the renewal practice. 33 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. 34 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 with their requirements. 35

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.

Incomplete registries

Recent attempts have been made to update the registers of healthcare 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 most extensive biometrics-based identification system in the world), professional bodies can improve the quality of their registries by demanding that healthcare professionals provide their Aadhar number at the time of re-registration. 36  As of 17 July 2017, over a million doctors had already registered their Aadhar numbers with the MCI. 37

The Arunachal Pradesh Medical Council (APMC) intimated that implementing a CME requirement in the state was problematic, as many doctors continued 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. 38

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. 39

In 2017, MCI directed all states to provide a unique permanent registration number (UPRN) to every doctor registered in their jurisdiction. 40 This initiative will end the duplication of doctors’ names being registered with various state medical councils and the Indian Medical Register under the MCI and provide a clear picture of how many doctors are practising in India. A UPRN number will be generated for the over 1 million doctors recorded in the IMR. A UPRN number will also greatly assist state medical councils in implementing CME practice.

Attendance at live CME events

A survey conducted by Manan D. Shah et al. 41  among predominantly male Indian specialist physicians about 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.42 

The demand to make CME mandatory in India calls for a critical balancing act. 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. 43 It was calculated that each demand to gain one CME credit using a live event meant a loss of approximately 8.96 million clinical hours for the 1.308 million physicians (Table 2).

 

Table 2: Time required for all Indian doctors to earn 1 CME credit
Number of Indian physicians (as on August 2022 per Indian Medical Register) 13,08,000, i.e. approx. (~1.308 million)
Study time required to earn one 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 a live event [6.85 x 1.308 million] = 8.96 million hours

Per Medical MCI guidelines, 44 attendance of 4 hrs of conference entitles a doctor to 1 CME credit.

** Travel time of 2.85 hours per credit is estimated by calculating a weighted average of rural and urban doctors, considering a minimum 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 about 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, could attend live events. Dr Moji suggested conducting CME at the district level in future. 45  The KMC tried to resolve the issue of travel time by dividing its state into 28 zonal districts and having live events at the district level. 46  However, travel time to an event is estimated to lead to a yearly loss of 21.94 million clinical hours (Table 3). Introducing 100% online CME would save one whole working week (35.1 hours) per year per physician.

 

Table 3: Time saved per doctor by 100% adoption of online CME
 
1. Clinical time spent in earning CME credits through live events
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
 
2. Clinical time spent in earning CME credits by the adoption of online CME
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
Note: All values are in hours.
3. Clinical time saved per doctor each year by 100% adoption of online CME
41.10 – 6, i.e. 35.10 hour
 

Each physician thus loses as much as 35.10 hours if he has to earn 6 annual credits through live events as opposed to online CME. For the total workforce of 1.308 million doctors, this means a staggering loss to the nation of 35.10 x 1 million = 45.03 million clinical hours. The way forward is to adopt online CME for all states.

Infrastructure

Organizing and supervising

Organizing and supervising CME activities is an arduous task for state medical councils. The procedure requires the 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 3,84 million conference days of CME events are required per year. If the attendance of 100 delegates is estimated, it would require 76,800 observation days per year (Table 4), excluding travel time.

Table 4: Calculation of observation days needed
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) 3.84 Million
Observers per conference day, considering 100 participants 2
Observation days (study days for all physicians x 2)/100) 76,800

A move towards online CME is thus inevitable to ensure that all physicians get adequate access to CME. In India, the National Knowledge Network 47 has been working since 2016 on the online education backbone, interlinking as many as 184 medical colleges to create a shared learning platform. Central and state government agencies have deployed this, bringing high-speed optic fibre-based Internet within reach of many healthcare 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.

Re-registration

The administrative burden on overstretched healthcare professionals will increase if the re-registration process remains manual. 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. 48 These charges may have assisted them in automating their CME process. This approach seems to have paid off, as their Website on 31 August 2022 compiles an overview of more than 354 fully accredited CME organizations, organizations with partial accreditation and organizations for case-to-case accreditation. They have accredited more than 952 general speakers and 66 speciality speakers. 49 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. 

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. 

Content

Online CME modules are gradually becoming available for Indian health professionals. Seventeen state medical councils accept online CME (see Table 1). In 2011, www.mycme.com was launched for Indian healthcare professionals at a Royal College of General Practitioners (RCGP) meeting in Delhi. 50 BMJ learning collaborates with the Delhi Medical Council and Karnataka Medical Council to accept the credits that their doctors acquire through online CME. 51, 52 The Gujarat Medical Council accepts credits from IMA e-varsity 53. This is an initiative by the Indian Medical Association, College of General Practitioners. The Tamil Nadu Medical Council initially approved their CME programme. The Maharashtra Medical Council accepts online education too, but only for 20% of the total credits for practitioners residing in Maharashtra. In comparison, those living outside their state benefit from 100% of the total credits.

There is an Indian edition of ‘GP Clinics’, 54, which caters 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. 55

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. 56 The Association of Physicians of India is also a player in the CME field with its yearly APICON congress and journal. 57

The National Medical Commission has a long-term running 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 the participation of NRI faculty from the USA/UK/Canada. This money is to meet the expenses of the visiting NRI faculty, including foreign faculty, if any, and for the publication of programme proceedings. They host 100 to 150 such programmes a year.

In 2014, Venkataraman R et al. 58 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. 59

A cost-effective initiative from the CME India Group (initially by the Association of Physicians, Jharkhand) is https://cmeindia.in/ . They compiled WhatsApp conversations by internal medicine physicians on more than 10 000 unique cases.

Ideally, online CME modules with international accreditation should be made available to Indian healthcare professionals, keeping in mind affordability and transparency about ties to the industry.

The way forward for CME in India

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.  Content aggregators should make a clear distinction 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. A declaration of interest should accompany every CME activity. 60

Conclusion

Online CME is gaining momentum in India. 17 out of 29 state medical councils accept online CME education. The MCI had recommended making CME and re-registration mandatory in 2007. Incomplete registries of practitioners hamper the implementation of CME and re-registration. Generating a UPRN for every practitioner is expected to streamline this matter. Although many healthcare professionals prefer live, interactive CME activities, these are impractical in terms of time management; and are out of reach for many rural practitioners. Automating the re-registration process is essential to ensure the feasibility of this task for state medical councils. There is a gradual increase of online CME modules in India, but affordability and transparency about ties to the industry need to be ensured.

Disclosure

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.

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