New NMC Regulations Discard CME Linked Renewals

With the publication of the “Registration of Medical Practitioners and Licence to Practice Medicine Regulations, 2023” [See] by the National Medical Commission on 10th May, 2023, our battle against CME linked renewals of registrations of medical practitioners under the medical councils has finally culminated in success. With this notification of Regulations, the issue of CME linked renewals has been finally buried.

This battle against the CME linked renewals started when the Karnataka Medical Council initiated the process in Dec 2013. [See] A RTI application was filed, seeking to know the legal basis for renewal of registration and its linkage to CME credits.[See] The KMC in its reply categorically stated that there was no legal basis for both, but it was going ahead based on its own decisions. A detailed analysis of the legal implications and potential harms to the medical practitioners of Karnataka was by Dr Srinivas Kakkilaya in his column Arogya Ashaya in a leading Kannada daily on April 2014. [See] But the medical practitioners of Karnataka chose to ignore these facts and went about attending CMEs to gather credit points for the next 2 years.

In April 2016, against its own directive of the need to have 30 points in 5 years, the KMC announced the beginning of the renewal process from May 2016! Spurred on by Dr Srinivas Kakkilaya, the medical practitioners of Karnataka joined together through WhatsApp and swiftly organised a campaign to Boycott Renewal and after any branches of the IMA in Karnataka endorsed the campaign, the Karnataka State IMA too sided with it. [See]

The CME linked renewal process initiated by the KMC was opposed mainly on the following three grounds:

  1. There was no provision for renewal of registration in the Indian Medical Council Act 1956.
  2. There was no provision for renewal of registration linked to CME credits in the Karnataka Medical Registration Act, and the amendments made in 2003 were not clear enough to be implemented nor were any rules made to implement them.
  3. Once registered on the basis of qualifications enlisted in the Schedules to the IMC Act, no fresh conditions or requirements such as CME Credits can be imposed, that too by the state medical councils, for maintaining the registrations and such registrations are therefore of permanent nature. Moreover, the Karnataka Medical Council having collected a life-time fee at the time of registration, and having issued certificates explicitly stating that the registrations are permanent, no renewal of the same can be demanded by the Council.

As a result of the campaign, the planned renewal process was agreed to be converted to only an updation process without charges. However, owing to the confusions and pressures, renewal and CME crediting did not stop. Considering these, Dr Srinivas Kakkilaya, Dr Divakar Rao, [See] Dr Yoganand Reddy and Dr Honne Gowda filed writ petitions before the Karnataka High Court seeking stay on the process and against removal of the names from the registers. The Hon’ble High Court granted interim stay against removal of the names of those who did not renew their registrations. Thereafter, more such petitions were filed and a similar stay was obtained for all the members of the IMA, Karnataka Branch.[See]

Later in 2017, amendments were made to the Karnataka Medical Registration Act to enable 5 yearly renewals with CME Credits of 6 hours per year. This has also been challenged before the Hon’ble High Court. Owing to all these, majority of the practitioners in Karnataka did not renew their registrations and the CME Credits lost their importance.

Meanwhile in 2018, the Government of India proposed to disband the Medical Council of India and published the report for setting up the National medical Commission. [See] This report categorically stated as below:

f. The Committee also deliberated upon inserting an additional enabling provision of voluntary recertification/ renewal of license exam once every ten years which is prevalent in many countries but it concluded that while desirable in the long run this may not be an appropriate time for such a radical step. The proposed changes will already entail substantial transition from the old to a new system and it would be imprudent to frontload this change.

Thereafter, the draft NMC Bill and also the final NMC Act enacted in 2019 did not provide for renewal of registrations nor for CME Credits for renewal or maintenance of registrations.

Therefore, as we had been consistently stating, there has never been any provision for renewal of our registrations, or for CME credits or CME linked renewals, either in the earlier IMC Act, 1956 or in the new NMC Act, 2019.

The IMC Act of 1952 had this clause:

PRIVELEGES OF PERSONS WHO ARE ENROLLED ON THE INDIAN MEDICAL REGISTER

  1. Subject to the conditions and restrictions laid down in this Act, regarding medical practice by persons possessing certain recognised medical qualifications, every person whose name is for the time being borne on the Indian Medical Register shall be entitled according to his qualifications to practice as a medical practitioner in any part of India and to recover in due course of law in respect of such practice any expenses, charges in respect of medicaments or other appliances, or any fees to which he may be entitled.

As per this section, any medical practitioner registered in any state medical council had the privilege to practice in any part of India.

How the NMC has changed these privileges?

But the NMC Act made a separate provision titled licence to practice medicine and elaborated it in Sec 33 as below:

  1. (1) Any person who qualifies the National Exit Test held under section 15 shall be granted a licence to practice medicine and shall have his name and qualifications enrolled in the National Register or a State Register, as the case may be.

Following this, the NMC published the Draft Regulations of Licence to Practice Medicine, 2022 on April 6, 2022 and called for submissions of objections within 30 days.[See]

We had submitted our objections very clearly as below:

  1.     (a) These Regulations may be referred as “Regulations of License to Practice Medicine, 2022”. 

We suggest that this may be better termed as “Regulations of Registration to Practice Medicine, 2022”, by replacing the word LICENSE with REGISTRATION 

  1. (e) “License” means a licence to practice medicine modern /allopathic medicine

We suggest that the word License be omitted; we also suggest that the word allopathy or allopathic, wherever they appear in the draft, be omitted and be replaced with the word modern scientific medicine. 

  1.     Designated authorities for granting Licence to Practice Medicine

3.1.  The Ethics & Medical Registration Board (EMRB), National Medical Commission (NMC) shall generate a Unique ID No. and thereby accord Licence to Practice Medicine to the practitioner in the respective State/Union Territory 

We suggest that the words in the respective State/Union Territory be omitted. 

The erstwhile Indian Medical Council Act 1956, under which all the practitioners of modern medicine in India are hitherto registered, has under Section 27 – Privileges of Persons Who Are Enrolled on The Indian Medical Register, very clearly provided that subject to the conditions and restrictions laid down in this Act, regarding medical practice by persons possessing certain recognised medical qualifications, every person whose name is for the time being borne on the Indian Medical Register shall be entitled according to his qualifications to practice as a medical practitioner in any part of India and to recover in due course of law in respect of such practice any expenses, charges in respect of medicaments or other appliances, or any fees to which he may be entitled. There being no clause in the NMC Act 2019 contravening this provision of the IMC Act, this above Draft Regulation 3.1 stating that a Unique ID No. (shall) accord Licence to Practice Medicine to the practitioner in the respective State/Union Territory will be restrictive and create several problems for the medical practitioners as well as patients. 

We therefore suggest that the words in the respective State/Union Territory shall be omitted. Any medical practitioner who is provided registration in the National Medical register shall be allowed to practice anywhere in India without any other conditions attached. This is very important for doctors working in border areas, and for specialists working in more than one hospital across regions. In the event of any proceedings that are required to be conducted for any complaints, the same can be conducted in the medical council of the state where the cause of action has occurred, and the same must be understood, acknowledged and accepted by the practitioner. 

  1.     DURATION OF LICENCE TO PRACTICE MEDICINE

4.1 The validity of Licence to Practice Medicine is subject to the following- (a) request received from the Licenced Medical Practitioner for whatsoever reasons, to withdraw / discontinue with the Licence to Practice; (b) may be cancelled / withdrawn if at any time it is found that the Licence to Practice does not possess/ or has not fulfilled the necessary eligibility requirements; (c) continuation of licence to practice after specific periods or re-licencing after specified periods may be dependent on regulations made for the purpose. 

We suggest that the sub clause C of Sec 4.1, namely, (c) continuation of licence to practice after specific periods or re-licencing after specified periods may be dependent on regulations made for the purpose, be omitted in toto. 

According to this very Sec 4.1, the registration once accorded can only be removed under sub clauses a & b. Therefore, keeping sub clause c will create confusion and provide opportunity for misuse by some state medical councils insisting on renewals, re-licensing etc., by imposing conditions at their own whims and fancies, beyond the conditions required for registration as mandated under the NMC Act or IMC Act. At present, only a few state councils have mandated CME linked renewals, and in some states such as Karnataka, these demands have been stayed by the High Courts. The Preliminary Report of the Committee on the Reform of the Indian Medical Council Act, 1956 by NITI Aayog, dated Aug 7, 2016 had clearly stated in Sec 3.7 (f) thus: ‘The Committee also deliberated upon inserting an additional enabling provision of voluntary recertification/ renewal of license exam once every ten years which is prevalent in many countries but it concluded that while desirable in the long run this may not be an appropriate time for such a radical step. The proposed changes will already entail substantial transition from the old to a new system and it would be imprudent to frontload this change. The subsequent NMC Act also nowhere provides for re-licensing or renewals. Therefore, such an open-ended clause for registration for specific periods or re-licencing after specified periods will lead to several problems, and these will affect the practitioners of only such states that harp on such measures, putting only such doctors in trouble. The problems and confusions will be compounded for doctors who are practicing in more than one state, if these states have different regulations.

The NMC had thereafter published the Draft National Medical Commission Registered Medical Practitioner (Professional Conduct) Regulations, 2022 on May 23, 2022 seeking objections within 30 days.[See] The following objection with regard to the Clause V on CMEs was filed on June 23, 2022:

In response to the Draft National Medical Commission Registered Medical Practitioner (Professional Conduct) Regulations, 2022, I am hereby submitting my objections and suggestions.

I – Clause 5

Clause 5: Continuing Professional Development Program – A RMP should attend continuing professional development programs regularly each year, totaling at least 30 credit hours every five years. Only recognized medical colleges and health institutions or medical societies accredited or authorized by EMRB/State medical Councils can offer training and credit hours for this purpose. Credit hours awarded shall be updated online against the Unique Registration Number of RMP on the EMRB-NMC website. Renewal of License to practice should be done every 5 years (from the publication of the Gazette notification), after submitting documentation of CPD credit hours. The license renewal form will allow updates of details like specialization, place of work, address, contact details, or any other detail specified by EMRB/NMC. RMPs who wish to practice in another State (due to transfer of work of residence) should inform that State Medical Council and apply for License to practice in that State. State will have to mandatorily provide license to practice charging appropriate fee within 7 days.

This entire Clause 5 must be omitted for the following reasons:

A RMP should attend continuing professional development programs regularly each year, totaling at least 30 credit hours every five years. Only recognized medical colleges and health institutions or medical societies accredited or authorized by EMRB/State medical Councils can offer training and credit hours for this purpose. Credit hours awarded shall be updated online against the Unique Registration Number of RMP on the EMRB-NMC website. Renewal of License to practice should be done every 5 years (from the publication of the Gazette notification), after submitting documentation of CPD credit hours.

This part of Clause 5 has no basis in law.

  1.   The NMC Act DOES NOT provide for any renewal
  1.   The NMC Act DOES NOT provide for the need for any CMEs/CPDs to maintain the registration or to renew the registration
  1.   The NMC Act DOES NOT provide for any need for any credit hours, nor does it specify any limits, 30 hours or otherwise.
  1.   The NMC Act DOES NOT provide for any powers to either the NMC or the EMRB or the SMCs to accredit or authorise anybody to offer training or credit hours.

Registration of a medical practitioner in India is SOLELY done on the basis of conditions listed under Sections 33,34,35 of the NMC Act. No new conditions or qualifications for registration or maintenance of it can be introduced under the pretext of Regulations. Therefore, imposing these requirements of CPDs, credit hours, their prior approvals etc., are completely beyond the scope of the NMC Act and the Regulations thereunder and therefore should be completely abandoned.

When a very similar attempt was made by the Karnataka Medical Council in 2013-2016, imposing the very similar CMEs and 30 credit hours in 5 years, it was opposed by the medical practitioners of Karnataka. The matter was challenged before the Hon’ble High Court of Karnataka in multiple Writ Petitions filed between Dec 2016 and Feb 2017 [WP 65832-34/2016 (Drs Yogananda Reddy, Honnegowda), WP 65861-65862/2016 (Drs Divaker Rao, Srinivas Kakkilaya),WP 407-421/2017 (Dr Mukund and others), WP 820-832/2017 (Dr BS Kakkilaya, Mandya and others), WP 954-983/2017 (Dr PV Bhandary and others), WP 1584-93/2017 (Linked to Dr BS Kakkilaya and others), WP 21234/2017 (Dr Shripad and others), WP 40580/2017 (Drs Yogananda Reddy and Honnegowda on behalf of IMA KSB) and the Hon’ble High Court had issued stay orders against the State Medical Council against removing any names from the register for not having the CME credits. The stay order remains in force and the matter remains sub-judice. Some of these petitions have challenged the powers of the medical council to impose conditions for registrations that are beyond the Schedules or other Sections of the principal Acts. The present attempt in this Draft, which seems to be a copy-paste of what was done by the Karnataka Medical Council earlier, is also beyond the scope of the NMC Act as already mentioned here above.

Further, the Preliminary Report of the Committee on the Reform of the Indian Medical Council Act, 1956 by NITI Aayog, dated Aug 7, 2016 had clearly stated in Sec 3.7 (f) thus: ‘The Committee also deliberated upon inserting an additional enabling provision of voluntary recertification/ renewal of license exam once every ten years which is prevalent in many countries but it concluded that while desirable in the long run this may not be an appropriate time for such a radical step. The proposed changes will already entail substantial transition from the old to a new system and it would be imprudent to frontload this change.’

It is crystal clear therefore that the issue of renewal or relicensing was considered inappropriate and imprudent by the NITI Aayog and was also not included under the NMC Act that was passed by the Parliament of India. Therefore, bringing in such an unnecessary and troublesome measure under the pretext of Regulations is completely against the letter and spirit of the NMC Act, Niti Ayog and our Parliament.

These provisions for CPDs, credit points, their prior approval etc., appear to be intended to provide money-making business opportunities for various organisations and companies. This will also pave the way for online Edutech companies to create platforms for CPDs, allowing them to fleece the RMPs. At present, such CMEs and conferences are mostly being organised with the active support of the pharma and medical equipment companies, and it is an open secret that such programmes are at the root of corrupting the RMPs. It is also well known that many medical organisations are using these conferences and CMEs to collect and amass funds and therefore, such organisations tend not to question or oppose making the CMEs/Conferences mandatory, even if that is not in accordance with the laws. Therefore, when the Draft regulations have several clauses related to regulating such funding and their disclosures, it is indeed shocking that the EMRB and NMC have made proposals under the Professional Conduct Regulations for RMPs for promoting conferences/CMEs/CPDs etc., thereby contradicting and defeating the very purpose of these Draft Regulations.

Further, many of the publications in many of the medical journals are now available for open and free access, and there are umpteen resources from many prestigious institutions that provide excellent updates for free. None of these can be dishonoured, nor can be expected to be pre-approved by any SMC or EMRB. In such a situation, any proposal to mandate CPDs that are pre-approved by EMRB or SMCs is not only retrograde, but also insulting.

Therefore, this entire clause on CPDs, credit hours, pre-approvals must be completely withdrawn.

The second part of this Clause 5 is as below:

The license renewal form will allow updates of details like specialization, place of work, address, contact details, or any other detail specified by EMRB/NMC.

The intention of this part of the Clause is to keep the records of the RMP on the National register updated. This is desirable. However, this need not be and should not be linked to CPDs and Credit Hours. The RMP should be allowed to update the details as and when needed, and not necessarily only once in 5 years.

The third part of this Clause 5 is as below:

RMPs who wish to practice in another State (due to transfer of work of residence) should inform that State Medical Council and apply for License to practice in that State. State will have to mandatorily provide license to practice charging appropriate fee within 7 days.

The erstwhile Indian Medical Council Act 1956, under which all the practitioners of modern medicine in India are hitherto registered, has under Section 27 – Privileges of Persons Who Are Enrolled on The Indian Medical Register, very clearly provided that subject to the conditions and restrictions laid down in this Act, regarding medical practice by persons possessing certain recognised medical qualifications, every person whose name is for the time being borne on the Indian Medical Register shall be entitled according to his qualifications to practice as a medical practitioner in any part of India and to recover in due course of law in respect of such practice any expenses, charges in respect of medicaments or other appliances, or any fees to which he may be entitled. There being no clause in the NMC Act 2019 contravening this provision of the IMC Act, this above part of Clause 5 stating that RMPs who wish to practice in another State (due to transfer of work of residence) should inform that State Medical Council and apply for License to practice in that State will be restrictive and create several problems for the medical practitioners as well as patients.

Therefore, in Clause 5, the words apply for License to practice in that State and State will have to mandatorily provide license to practice charging appropriate fee within 7 days must be omitted in toto. Any medical practitioner who is provided registration in the National Medical register shall be allowed to practice anywhere in India without any other conditions attached. This is very important for doctors working in border areas, and for specialists working in more than one hospital across regions. In the event of any proceedings that are required to be conducted for any complaints, the same can be conducted in the medical council of the state where the cause of action has occurred, and the same must be understood, acknowledged and accepted by the practitioner.

The final form of the Registration of Medical Practitioners and Licence to Practice Medicine Regulations, 2023, published on May 10, 2023, [See] is substantially different from the draft regulations published on April 6, 2022. The term allopathic medicine has been removed, except in one paragraph. Most importantly, as we had demanded with regard to both the Draft Regulations of Licence to Practice Medicine, 2022 published on April 6, 2022 and the Draft National Medical Commission Registered Medical Practitioner (Professional Conduct) Regulations, 2022 published on May 23, 2022, the proposals made for continuation of licence to practice after specific periods or re-licencing after specified periods may be dependent on regulations made for the purpose and for Continuing Professional Development Program regularly each year, totaling at least 30 credit hours every five years, conducted by only recognized medical colleges and health institutions or medical societies accredited or authorized by EMRB/State medical Councils and for renewal of License to practice to be done every 5 years after submitting documentation of CPD credit hours has been completely omitted. With this, our demands for stopping the CME linked renewals have been fully met and the CME Credit linked renewal has been stopped by the NMC forever. We thank the NMC for accepting our demands in this regard.

Also, the proposal for continuation of licence to practice after specific periods or re-licencing after specified periods may be dependent on regulations made for the purpose having been omitted from the final form of the regulations, our demand not to allow the state medical councils to make their own regulations for renewals, CME Credits etc., has also been honoured and the state medical councils have not been given any such powers. We are grateful to the NMC for accepting that suggestion of ours too.

Although these demands have been conceded by the NMC and the proposed CME credit linked renewals have been completely dropped, the new regulations are not free from concerns. While the earlier IMC Act, 1956 did not differentiate registration from licence to practice and allowed every registered medical practitioner the privilege to practice in any part of India, the new regulations have separated the registration of a medical practitioner from the licence to practice. According to the new regulations, anyone who undergoes the prescribed training and passes the required examinations gets the registration under the EMRB of NMC and also gets the initial licence to practice in the state of choice. However, after 5 years, and every 5 years thereafter, the registered practitioner must apply once again on the EMRB portal, pay the prescribed fees, choose a state and obtain the licence to practice, and if that is not done, the registration will be converted as inactive and the person shall not be entitled to practice medicine. All those practitioners who are already registered under the IMC Act must also now submit their applications for obtaining this licence on the EMRB portal, as and when the facility is provided, the first such licence being provided free of charges, and they will have to apply again after 5 years by paying the prescribed fees at the time. As has been clearly stated above, no state medical council can demand any CME credits or any other conditions for granting such a licence.

The bigger concern in the new regulations is the requirement to obtain the licence from the medical council of one state or union territory and to transfer it to another state so as to practice there. Such a requirement would mean that a medical practitioner can obtain the licence from only one state. There being no option to obtain licences from multiple states, a licence restricted to one state will definitely hamper the work of many medical practitioners who are working in two adjacent states or providing their expert services in multiple states. This new requirement completely negates the privilege accorded by the earlier IMC Act 1956, Sec 27, to every practitioner to practice in any part of India. Therefore, the NMC must immediately rectify this glaring lapse by either providing the option to get licence in multiple states or pan India for the same single fees.