To renew their licenses in Colorado, attorneys must prove they’ve taken continuing education courses. So do accountants, physician’s assistants, teachers, and anyone who sells life insurance or real estate.

Physicians do not.

Colorado is one of only four states that does not require any continuing medical education for physicians. Not only does Colorado not require doctors to complete continuing education courses in order to renew their licenses, the state’s Medical Practice Act actually forbids the state medical board from requiring continuing education. But one Colorado physician, a former president of the state medical society, is urging that prohibition be removed.

A fifth state, New York, does not require coursework hours but does mandate specific courses on infection control, painkiller prescribing, and training in identifying and reporting child abuse.

Starting in 2019, one of the four other states, Indiana, will require physicians to complete courses on opioid abuse and prescribing. The legislation adding that requirement received widespread support from doctors’ and nurses’ groups, including the Indiana State Medical Association. Indiana is now one of 17 states that require continuing education on controlled substances.

That leaves just three states — Montana, South Dakota and Colorado — with no continuing education requirement whatsoever, said Gene Richer, director of continuing education for the Colorado Medical Society. To renew a license in this state, as they must do every two years, Colorado’s 24,885 active physicians need only to prove they have malpractice insurance, and pay a fee.

Map by Jesse Paul, The Colorado Sun. Data from the Colorado Medical Society.

Many doctors obtain what is known as board certification in a specialty. In fact, according to the American Board of Medical Specialties, 880,000 of the nation’s one million-plus doctors are certified in at least one of 39 recognized specialties. To be board certified, physicians must regularly demonstrate knowledge in their particular specialty to the governing body of that specialty.

And while requirements differ among specialties, that demonstration of knowledge typically involves some proof of continuing education. However, that education tends to be narrowly focused on the specialty and may or may not include general information on topics like infection control or best practices for prescribing pain medications.

In addition, many hospitals and health care systems have continuing education requirements for physicians they employ or contract with.

The result is that most Colorado doctors probably have to demonstrate some ongoing knowledge growth at some point.

What’s more, said Dr. Lynn Parry, a Littleton neurologist and former president of the Colorado Medical Society, most physicians who don’t practice in a hospital or aren’t certified in a specialty “probably still read journals and stay up on information.”

But most is not all.

“There will always be a small percentage of people who … practice based on what they learned in medical school 30 years ago. There would be fewer of those if there were basic requirements for CME,” Parry said.

She feels strongly about that. In August, she wrote to the state medical board, asking its 16 members to consider allowing a CME requirement for physicians not already required to complete additional courses.

In her letter, Parry pointed out that rules for CME courses have been tightened in recent decades, in an effort to prevent influence by commercial interests like drug and medical device companies that tainted courses in the past.

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“A physician entering practice in 1950 could expect medical knowledge to double over the next 50 years. By 2020 medical knowledge will double every 73 days,” Parry wrote. Without a CME requirement, “Will the [medical board] be able to assure the public that public safety is protected — particularly in times of crisis?”

The letter was part of a state-mandated sunset review of the Medical Practice Act. As part of that review, the Colorado Office of Policy, Research and Regulatory Reform surveyed the state’s licensed physicians about licensing requirements. Only 10 percent responded; of those, 68.5 percent said they didn’t want continuing medical education requirements, while 95 percent said they took CME classes anyway.

Dr. Brenda Bucklin, associate dean for CME and professional development at the University of Colorado Medical School, said she isn’t sure a minimum requirement would make a big difference in the state.

“I think most people participate anyway,” Bucklin said. She said 27,000 physicians participated in CU’s continuing education program last year, although not all were from Colorado.

CU offers scholarships and reduced tuition for some physicians who would find it difficult to pay the cost of some courses, which can run into the hundreds of dollars, not including the cost of a day or two spent learning and not practicing medicine, Bucklin said.

Colorado did have CME requirements in the past, said pediatrician Dr. Richard Krugman, professor and former dean of the University of Colorado School of Medicine. He said his recollection is that the requirement was removed in the 1970s or ‘80s, largely because there was little evidence at the time that continuing education was beneficial.

Krugman, a nationally recognized authority on the treatment and prevention of child abuse, said that early in his career, “most physicians I knew kept up with changes, went to grand rounds. But I saw lots of pediatricians who were still doing things the way they had been doing them for 20 years. Was that bad for children? I don’t know.”

Research indicates that it might be.

A 2002 study published in the journal Medical Education found that heart attack patients whose physicians — both cardiologists and internal medicine specialists — had successfully passed the examinations required by their specialties for certification had a nearly 20 percent lower rate of dying.

And a 2015 review of previous studies concluded that “CME improves physicians’ performance and patient health outcomes.”

Bucklin sees evidence that CME makes a difference for Colorado physicians, too.

In 2017, 97 percent of physicians who participated in the live courses offered by her department said they would make changes to their practice as a result of what they learned.

That is the point, and the benefit, of continuing education, Parry said. And that is why she is so passionate about it.

“It still is not completely embraced by all physicians,” she said. Like any other medical quality measure or control, Parry said, continuing education isn’t a guarantee. “But it certainly goes a long way toward achieving quality.”

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